Provider Demographics
NPI:1720590946
Name:DILWORTH, LETICIA (BA)
Entity Type:Individual
Prefix:
First Name:LETICIA
Middle Name:
Last Name:DILWORTH
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:4221 WILSHIRE BLVD STE 300A
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90010-3537
Mailing Address - Country:US
Mailing Address - Phone:323-866-1880
Mailing Address - Fax:323-866-1881
Practice Address - Street 1:3610 CENTRAL AVE STE 46
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92506
Practice Address - Country:US
Practice Address - Phone:888-428-3223
Practice Address - Fax:323-866-1881
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-27
Last Update Date:2019-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10798420-2506103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst