Healthcare Provider Details

I. General information

NPI: 1154154557
Provider Name (Legal Business Name): MARIELA PATRICIA HUAZANO HEREDIA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/21/2024
Last Update Date: 04/23/2026
Certification Date: 04/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

855 N ORANGE GROVE BLVD STE 207
PASADENA CA
91103-3333
US

IV. Provider business mailing address

PO BOX 1541
MECCA CA
92254-1541
US

V. Phone/Fax

Practice location:
  • Phone: 626-296-8900
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number131212
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: