Provider Demographics
NPI:1275669731
Name:HENNESSEY, LETICIA S (PSYD)
Entity Type:Individual
Prefix:DR
First Name:LETICIA
Middle Name:S
Last Name:HENNESSEY
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:DR
Other - First Name:LETICIA
Other - Middle Name:
Other - Last Name:SOLORZANO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PSYD
Mailing Address - Street 1:PO BOX 609001
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92160-9001
Mailing Address - Country:US
Mailing Address - Phone:619-528-4600
Mailing Address - Fax:619-528-4625
Practice Address - Street 1:1061 TIERRA DEL REY
Practice Address - Street 2:#200
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91910-7880
Practice Address - Country:US
Practice Address - Phone:619-498-5454
Practice Address - Fax:619-498-5455
Is Sole Proprietor?:No
Enumeration Date:2007-02-26
Last Update Date:2020-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
W416Medicare PIN