Provider Demographics
NPI:1598305245
Name:HERMOSILLO, ROSITA D
Entity type:Individual
Prefix:
First Name:ROSITA
Middle Name:D
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 1:11801 PIERCE ST STE 200
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92505-4400
Mailing Address - Country:US
Mailing Address - Phone:951-783-9096
Mailing Address - Fax:
Practice Address - Street 1:11801 PIERCE ST STE 200
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92505-4400
Practice Address - Country:US
Practice Address - Phone:951-783-9096
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-10
Last Update Date:2024-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1180151041C0700X
CA93713104100000X, 104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty