Basic Information
| Provider Information | |||||||||
| NPI: | 1740359488 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HUMEREZ | ||||||||
| FirstName: | SONIA | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | LMFT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 432 CAMBRIDGE AVE | ||||||||
| Address2: | 1215 SW G STREET | ||||||||
| City: | GRANTS PASS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97526 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5414762373 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3156 STATE ST | ||||||||
| Address2: | |||||||||
| City: | MEDFORD | ||||||||
| State: | OR | ||||||||
| PostalCode: | 975048450 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5414762373 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/07/2006 | ||||||||
| LastUpdateDate: | 01/17/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 106H00000X | 0092281 | NM | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
ID Information
| ID | Type | State | Issuer | Description | 46300 | 05 | NM | MEDICAID | 76955869 | 05 | NM | MEDICAID |