Provider Demographics
NPI:1073917084
Name:CORREA, MAYRA
Entity Type:Individual
Prefix:
First Name:MAYRA
Middle Name:
Last Name:CORREA
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 1:14624 SHERMAN WAY
Mailing Address - Street 2:SUITE 303
Mailing Address - City:VAN NUYS
Mailing Address - State:CA
Mailing Address - Zip Code:91405-2241
Mailing Address - Country:US
Mailing Address - Phone:818-908-4990
Mailing Address - Fax:
Practice Address - Street 1:14624 SHERMAN WAY
Practice Address - Street 2:SUITE 303
Practice Address - City:VAN NUYS
Practice Address - State:CA
Practice Address - Zip Code:91405-2241
Practice Address - Country:US
Practice Address - Phone:818-908-4990
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-20
Last Update Date:2014-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner