Provider Demographics
NPI:1366190969
Name:ESTRADA, MARYELLEN T (LADC)
Entity type:Individual
Prefix:MRS
First Name:MARYELLEN
Middle Name:T
Last Name:ESTRADA
Suffix:
Gender:F
Credentials:LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:240 WARDWELL ST APT 24
Mailing Address - Street 2:
Mailing Address - City:STAMFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06902-5241
Mailing Address - Country:US
Mailing Address - Phone:203-962-4929
Mailing Address - Fax:
Practice Address - Street 1:240 WARDWELL ST APT 24
Practice Address - Street 2:
Practice Address - City:STAMFORD
Practice Address - State:CT
Practice Address - Zip Code:06902-5241
Practice Address - Country:US
Practice Address - Phone:203-962-4929
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-13
Last Update Date:2022-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001332101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)