Provider Demographics
NPI:1649538067
Name:COSTILLA, LETICIA (CAS1)
Entity type:Individual
Prefix:MS
First Name:LETICIA
Middle Name:
Last Name:COSTILLA
Suffix:
Gender:F
Credentials:CAS1
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:515 S CEDAR AVE
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93702-2908
Mailing Address - Country:US
Mailing Address - Phone:559-600-8300
Mailing Address - Fax:
Practice Address - Street 1:515 S CEDAR AVE
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93702-2908
Practice Address - Country:US
Practice Address - Phone:559-600-8300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-24
Last Update Date:2012-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)