Provider Demographics
NPI:1639954431
Name:DURAN HERRERA, IMELDA
Entity Type:Individual
Prefix:
First Name:IMELDA
Middle Name:
Last Name:DURAN HERRERA
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 1:762 CYPRESS ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIMAS
Mailing Address - State:CA
Mailing Address - Zip Code:91773-3505
Mailing Address - Country:US
Mailing Address - Phone:909-599-1227
Mailing Address - Fax:
Practice Address - Street 1:762 CYPRESS ST
Practice Address - Street 2:
Practice Address - City:SAN DIMAS
Practice Address - State:CA
Practice Address - Zip Code:91773-3505
Practice Address - Country:US
Practice Address - Phone:909-599-1227
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-29
Last Update Date:2024-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA116839104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker