Healthcare Provider Details

I. General information

NPI: 1578473161
Provider Name (Legal Business Name): MAYRA NOLASCO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/08/2026
Last Update Date: 09/08/2026
Certification Date: 09/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15200 FOOTHILL BLVD
CASTRO VALLEY CA
94578-1013
US

IV. Provider business mailing address

1721 UNIVERSITY AVE APT 205
BERKELEY CA
94703-1558
US

V. Phone/Fax

Practice location:
  • Phone: 510-352-9690
  • Fax: 510-352-9008
Mailing address:
  • Phone: 510-706-1718
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code373H00000X
TaxonomyDay Training/Habilitation Specialist
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: