Provider Demographics
NPI:1770354524
Name:ESTRADA, ALEXANDRA SHANDALE
Entity type:Individual
Prefix:
First Name:ALEXANDRA
Middle Name:SHANDALE
Last Name:ESTRADA
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:ALEXANDRA
Other - Middle Name:SHANDALE
Other - Last Name:HUDSON-HENDERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:504 1ST ST
Mailing Address - Street 2:
Mailing Address - City:TULAROSA
Mailing Address - State:NM
Mailing Address - Zip Code:88352-2702
Mailing Address - Country:US
Mailing Address - Phone:575-491-0556
Mailing Address - Fax:
Practice Address - Street 1:504 1ST ST
Practice Address - Street 2:
Practice Address - City:TULAROSA
Practice Address - State:NM
Practice Address - Zip Code:88352-2702
Practice Address - Country:US
Practice Address - Phone:575-430-5166
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-10
Last Update Date:2025-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCTB-2024-0812101Y00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No101Y00000XBehavioral Health & Social Service ProvidersCounselor