=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902350374
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARA ISABEL IRIZARRY HERNANDEZ M.S.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/15/2016
-----------------------------------------------------
Last Update Date | 08/02/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 431 AVE HOSTOS
-----------------------------------------------------
City | SAN JUAN
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00918-3014
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-704-0705
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2121 W TEMPLE ST BUILDING A, B, & C
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90026-4915
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 213-260-7600
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | 7367
-----------------------------------------------------
License Number State | PR
-----------------------------------------------------