Provider Demographics
NPI:1770637993
Name:BERMEJO, SOILA MAREZ (RAS)
Entity Type:Individual
Prefix:MS
First Name:SOILA
Middle Name:MAREZ
Last Name:BERMEJO
Suffix:
Gender:F
Credentials:RAS
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 2087
Mailing Address - Street 2:
Mailing Address - City:MERCED
Mailing Address - State:CA
Mailing Address - Zip Code:95344-0087
Mailing Address - Country:US
Mailing Address - Phone:209-381-6880
Mailing Address - Fax:209-723-6220
Practice Address - Street 1:3305 G ST BLDG G
Practice Address - Street 2:
Practice Address - City:MERCED
Practice Address - State:CA
Practice Address - Zip Code:95340-0964
Practice Address - Country:US
Practice Address - Phone:209-381-6880
Practice Address - Fax:209-723-6220
Is Sole Proprietor?:No
Enumeration Date:2007-01-23
Last Update Date:2014-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAB0503162013101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAB0503162013OtherALCOHOL AND DRUG CERTIFIC