Healthcare Provider Details

I. General information

NPI: 1225493836
Provider Name (Legal Business Name): MS. LETICIA FACUNDO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/24/2015
Last Update Date: 02/26/2021
Certification Date: 02/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11041 VALLEY BLVD
EL MONTE CA
91731-2516
US

IV. Provider business mailing address

1460 E HOLT AVE STE 166
POMONA CA
91767-5852
US

V. Phone/Fax

Practice location:
  • Phone: 626-442-4177
  • Fax:
Mailing address:
  • Phone: 909-865-0209
  • Fax: 909-865-0185

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number2588
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number7227
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: