Provider Demographics
NPI:1235750266
Name:HERNANDEZ, MAYRA ALEJANDRA (ASW92336)
Entity Type:Individual
Prefix:
First Name:MAYRA
Middle Name:ALEJANDRA
Last Name:HERNANDEZ
Suffix:
Gender:F
Credentials:ASW92336
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 W MANCHESTER AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90003-3324
Mailing Address - Country:US
Mailing Address - Phone:866-590-6411
Mailing Address - Fax:
Practice Address - Street 1:130 W MANCHESTER AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90003-3324
Practice Address - Country:US
Practice Address - Phone:866-590-6411
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-30
Last Update Date:2020-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAASW923361041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty