Provider Demographics
NPI:1669092359
Name:ISIDORO, MAYRA YADIRA
Entity type:Individual
Prefix:
First Name:MAYRA
Middle Name:YADIRA
Last Name:ISIDORO
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 1:177 S VILLA AVE
Mailing Address - Street 2:
Mailing Address - City:ELMHURST
Mailing Address - State:IL
Mailing Address - Zip Code:60126-3030
Mailing Address - Country:US
Mailing Address - Phone:630-843-2149
Mailing Address - Fax:
Practice Address - Street 1:58 E CLINTON ST
Practice Address - Street 2:
Practice Address - City:JOLIET
Practice Address - State:IL
Practice Address - Zip Code:60432-4143
Practice Address - Country:US
Practice Address - Phone:815-723-0331
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-22
Last Update Date:2020-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)