Provider Demographics
NPI:1215202775
Name:MASCORRO, DAISY
Entity Type:Individual
Prefix:
First Name:DAISY
Middle Name:
Last Name:MASCORRO
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 1:867 N FAIR OAKS AVE
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91103-3050
Mailing Address - Country:US
Mailing Address - Phone:626-376-6585
Mailing Address - Fax:
Practice Address - Street 1:867 N FAIR OAKS AVE
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91103
Practice Address - Country:US
Practice Address - Phone:626-376-6585
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-16
Last Update Date:2022-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X, 106H00000X, 390200000X
CA133906106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program