Provider Demographics
NPI:1902043904
Name:MACIAS, MARIELA HERMOSILLO (LMP)
Entity Type:Individual
Prefix:MISS
First Name:MARIELA
Middle Name:HERMOSILLO
Last Name:MACIAS
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1209 MEADE AVE
Mailing Address - Street 2:
Mailing Address - City:PROSSER
Mailing Address - State:WA
Mailing Address - Zip Code:99350
Mailing Address - Country:US
Mailing Address - Phone:509-786-3637
Mailing Address - Fax:509-786-7385
Practice Address - Street 1:1209 MEADE AVE
Practice Address - Street 2:
Practice Address - City:PROSSER
Practice Address - State:WA
Practice Address - Zip Code:99350-1423
Practice Address - Country:US
Practice Address - Phone:509-786-3637
Practice Address - Fax:509-786-7385
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-13
Last Update Date:2009-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60055792225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist