Provider Demographics
NPI:1295958114
Name:BERNAL, LETICIA R (LBSW)
Entity type:Individual
Prefix:MRS
First Name:LETICIA
Middle Name:R
Last Name:BERNAL
Suffix:
Gender:F
Credentials:LBSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2020 W 17TH ST
Mailing Address - Street 2:
Mailing Address - City:ODESSA
Mailing Address - State:TX
Mailing Address - Zip Code:79763-2671
Mailing Address - Country:US
Mailing Address - Phone:432-557-7155
Mailing Address - Fax:
Practice Address - Street 1:2020 W 17TH ST
Practice Address - Street 2:
Practice Address - City:ODESSA
Practice Address - State:TX
Practice Address - Zip Code:79763-2671
Practice Address - Country:US
Practice Address - Phone:432-557-7155
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX29967104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker