Provider Demographics
NPI:1962876656
Name:ESTRADA, MAYLENE
Entity type:Individual
Prefix:
First Name:MAYLENE
Middle Name:
Last Name:ESTRADA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10218 BLACK MOUNTAIN RD APT 57
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92126-3806
Mailing Address - Country:US
Mailing Address - Phone:858-397-2180
Mailing Address - Fax:
Practice Address - Street 1:10218 BLACK MOUNTAIN RD APT 57
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92126-3806
Practice Address - Country:US
Practice Address - Phone:858-397-2180
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-18
Last Update Date:2015-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA9559225200000X, 251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
No251E00000XAgenciesHome Health