Provider Demographics
NPI:1710229547
Name:MCCOY, LETICIA ELISE
Entity Type:Individual
Prefix:
First Name:LETICIA
Middle Name:ELISE
Last Name:MCCOY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:37 SAN CLEMENTE DR APT 108
Mailing Address - Street 2:
Mailing Address - City:CORTE MADERA
Mailing Address - State:CA
Mailing Address - Zip Code:94925-3301
Mailing Address - Country:US
Mailing Address - Phone:415-378-6061
Mailing Address - Fax:
Practice Address - Street 1:37 SAN CLEMENTE DR APT 108
Practice Address - Street 2:
Practice Address - City:CORTE MADERA
Practice Address - State:CA
Practice Address - Zip Code:94925-3301
Practice Address - Country:US
Practice Address - Phone:415-378-6061
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-19
Last Update Date:2013-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker