Provider Demographics
NPI:1982103065
Name:ESTRELLA, TANIA IVETTE
Entity type:Individual
Prefix:
First Name:TANIA
Middle Name:IVETTE
Last Name:ESTRELLA
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 1:6591 162ND ST APT 2L
Mailing Address - Street 2:
Mailing Address - City:FRESH MEADOWS
Mailing Address - State:NY
Mailing Address - Zip Code:11365-2648
Mailing Address - Country:US
Mailing Address - Phone:917-943-0954
Mailing Address - Fax:
Practice Address - Street 1:225 BROADHOLLOW RD STE 402
Practice Address - Street 2:
Practice Address - City:MELVILLE
Practice Address - State:NY
Practice Address - Zip Code:11747-4899
Practice Address - Country:US
Practice Address - Phone:631-385-7780
Practice Address - Fax:631-385-7795
Is Sole Proprietor?:No
Enumeration Date:2018-02-05
Last Update Date:2018-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician