Provider Demographics
NPI:1902350374
Name:IRIZARRY HERNANDEZ, MARA ISABEL (MS)
Entity Type:Individual
Prefix:MS
First Name:MARA
Middle Name:ISABEL
Last Name:IRIZARRY HERNANDEZ
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2121 W TEMPLE ST
Mailing Address - Street 2:BUILDING A, B, & C
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90026-4915
Mailing Address - Country:US
Mailing Address - Phone:213-260-7600
Mailing Address - Fax:
Practice Address - Street 1:431 AVE HOSTOS
Practice Address - Street 2:
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00918-3014
Practice Address - Country:US
Practice Address - Phone:787-704-0705
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-15
Last Update Date:2022-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR7367103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical