Provider Demographics
NPI:1639674633
Name:SAN NICOLAS, MARA (MSW)
Entity Type:Individual
Prefix:
First Name:MARA
Middle Name:
Last Name:SAN NICOLAS
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 907
Mailing Address - Street 2:
Mailing Address - City:HAGATNA
Mailing Address - State:GU
Mailing Address - Zip Code:96932-0907
Mailing Address - Country:US
Mailing Address - Phone:671-777-0098
Mailing Address - Fax:
Practice Address - Street 1:400 ROUTE 8 STE 303
Practice Address - Street 2:
Practice Address - City:MAITE
Practice Address - State:GU
Practice Address - Zip Code:96910-2003
Practice Address - Country:US
Practice Address - Phone:671-475-0061
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-29
Last Update Date:2018-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HILSW-2466104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker