Provider Demographics
NPI:1467005645
Name:ESTRADA, LAURYN LEIGH (MA)
Entity type:Individual
Prefix:
First Name:LAURYN
Middle Name:LEIGH
Last Name:ESTRADA
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:LAURYN
Other - Middle Name:LEIGH
Other - Last Name:RANDALL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1605 LOCUST ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92106-2250
Mailing Address - Country:US
Mailing Address - Phone:714-483-2737
Mailing Address - Fax:
Practice Address - Street 1:16870 W BERNARDO DR STE 400
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92127-1678
Practice Address - Country:US
Practice Address - Phone:760-652-9680
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-17
Last Update Date:2021-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CA8567101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program