Provider Demographics
NPI:1417542937
Name:HERMOSILLO, MAYRA ALEJANDRA
Entity type:Individual
Prefix:
First Name:MAYRA
Middle Name:ALEJANDRA
Last Name:HERMOSILLO
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:PO BOX 1452
Mailing Address - Street 2:
Mailing Address - City:PASCO
Mailing Address - State:WA
Mailing Address - Zip Code:99301-1223
Mailing Address - Country:US
Mailing Address - Phone:509-547-2204
Mailing Address - Fax:509-542-8836
Practice Address - Street 1:715 W COURT ST
Practice Address - Street 2:
Practice Address - City:PASCO
Practice Address - State:WA
Practice Address - Zip Code:99301-4153
Practice Address - Country:US
Practice Address - Phone:509-547-2204
Practice Address - Fax:509-542-8836
Is Sole Proprietor?:No
Enumeration Date:2021-03-05
Last Update Date:2021-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WASC61148818104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker