Provider Demographics
NPI:1356650519
Name:HERNANDEZ, MARA IBEL (MS CCC-SLP)
Entity Type:Individual
Prefix:
First Name:MARA
Middle Name:IBEL
Last Name:HERNANDEZ
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7 CALLE RAUL JULIA
Mailing Address - Street 2:CERRO GORDO HILLS
Mailing Address - City:VEGA ALTA
Mailing Address - State:PR
Mailing Address - Zip Code:00692-9000
Mailing Address - Country:US
Mailing Address - Phone:787-648-6911
Mailing Address - Fax:
Practice Address - Street 1:7 CALLE RAUL JULIA
Practice Address - Street 2:CERRO GORDO HILLS
Practice Address - City:VEGA ALTA
Practice Address - State:PR
Practice Address - Zip Code:00692-9000
Practice Address - Country:US
Practice Address - Phone:787-648-6911
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-05
Last Update Date:2013-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR953235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist