Provider Demographics
NPI:1164004222
Name:DASALLA, MYRA ESTRELLA
Entity Type:Individual
Prefix:
First Name:MYRA
Middle Name:ESTRELLA
Last Name:DASALLA
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 1:306 E MAIN ST STE 307
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95202-2908
Mailing Address - Country:US
Mailing Address - Phone:209-478-4554
Mailing Address - Fax:209-478-1991
Practice Address - Street 1:306 E MAIN ST STE 307
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95202-2908
Practice Address - Country:US
Practice Address - Phone:209-478-4554
Practice Address - Fax:209-478-1991
Is Sole Proprietor?:No
Enumeration Date:2021-04-27
Last Update Date:2021-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health