Provider Demographics
NPI:1598305245
Name:HERMOSILLO, ROSITA D
Entity Type:Individual
Prefix:
First Name:ROSITA
Middle Name:D
Last Name:HERMOSILLO
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 1:555 N PERRIS BLVD
Mailing Address - Street 2:
Mailing Address - City:PERRIS
Mailing Address - State:CA
Mailing Address - Zip Code:92571-2811
Mailing Address - Country:US
Mailing Address - Phone:951-436-5366
Mailing Address - Fax:
Practice Address - Street 1:555 N PERRIS BLVD
Practice Address - Street 2:
Practice Address - City:PERRIS
Practice Address - State:CA
Practice Address - Zip Code:92571-2811
Practice Address - Country:US
Practice Address - Phone:951-436-5366
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-10
Last Update Date:2024-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA93713104100000X, 104100000X
CA1180151041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty