Provider Demographics
NPI:1043922461
Name:RAMIREZ, LETICIA (CADC-T)
Entity type:Individual
Prefix:
First Name:LETICIA
Middle Name:
Last Name:RAMIREZ
Suffix:
Gender:F
Credentials:CADC-T
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2101 HAMILTON RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31904-8834
Mailing Address - Country:US
Mailing Address - Phone:706-322-3773
Mailing Address - Fax:
Practice Address - Street 1:3150 PLATEAU DR LOT 303
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31903-5400
Practice Address - Country:US
Practice Address - Phone:706-322-3773
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-16
Last Update Date:2022-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA261QR0405X
GA26-4603737261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA26-4503737Medicaid