Provider Demographics
NPI:1992503114
Name:HEREDIA, MARITZA Y
Entity type:Individual
Prefix:
First Name:MARITZA
Middle Name:Y
Last Name:HEREDIA
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:723 SW 10TH ST
Mailing Address - Street 2:
Mailing Address - City:RENTON
Mailing Address - State:WA
Mailing Address - Zip Code:98057-5223
Mailing Address - Country:US
Mailing Address - Phone:206-461-4880
Mailing Address - Fax:
Practice Address - Street 1:723 SW 10TH ST
Practice Address - Street 2:
Practice Address - City:RENTON
Practice Address - State:WA
Practice Address - Zip Code:98057-5223
Practice Address - Country:US
Practice Address - Phone:206-461-4880
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-03-04
Last Update Date:2025-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator