Provider Demographics
NPI:1942848759
Name:ESTRELLA, EDNER BANAL
Entity Type:Individual
Prefix:
First Name:EDNER
Middle Name:BANAL
Last Name:ESTRELLA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24307 VERDUGO CIR
Mailing Address - Street 2:
Mailing Address - City:VALENCIA
Mailing Address - State:CA
Mailing Address - Zip Code:91354-4401
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:201 ALLEN AVE
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91201-2803
Practice Address - Country:US
Practice Address - Phone:818-845-8507
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-12
Last Update Date:2019-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA3824224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy AssistantGroup - Single Specialty