Provider Demographics
NPI:1962127829
Name:COLVILLE HERON, MYRNA JULIETA
Entity type:Individual
Prefix:
First Name:MYRNA JULIETA
Middle Name:
Last Name:COLVILLE HERON
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 1:2069 W SLAUSON AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90047-1022
Mailing Address - Country:US
Mailing Address - Phone:818-577-3695
Mailing Address - Fax:
Practice Address - Street 1:1318 W 88TH ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90044-2128
Practice Address - Country:US
Practice Address - Phone:323-333-3151
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-04
Last Update Date:2022-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health