Basic Information
| Provider Information | |||||||||
| NPI: | 1508210790 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HERNANDEZ-MORALES | ||||||||
| FirstName: | MAYRA | ||||||||
| MiddleName: | |||||||||
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| Credential: | AMFT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1902 MARENGO ST. SUITE #107 | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 90033 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3232766490 | ||||||||
| FaxNumber: | 3232766481 | ||||||||
| Practice Location | |||||||||
| Address1: | 1902 MARENGO ST. SUITE #107 | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 90033 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3232766490 | ||||||||
| FaxNumber: | 3232766481 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/14/2016 | ||||||||
| LastUpdateDate: | 08/06/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 08/06/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225400000X | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Rehabilitation Practitioner | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 106H00000X | AMFT116245 | CA | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.