MEDICARE: MERCEDES CANIZALEZ

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker

General Provider Information

NPI Number	:	1356119408
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MERCEDES CANIZALEZ

Provider Business Mailing Address
First Line	:	1663 E DATE PL # 3152
Second Line	:
City	:	SAN BERNARDINO
State	:	CA
Zip	:	92404-4496
Country	:	US
Telephone Number	:	909-294-6353
Fax Number	:

Provider Business Practice Location Address
First Line	:	1720 E 21ST ST
Second Line	:
City	:	SAN BERNARDINO
State	:	CA
Zip	:	92404-5619
Country	:	US
Telephone Number	:	909-294-6353
Fax Number	:

Authorized Official
Title or Position	:	SOLE OWNER
Name	:	MERCEDES CANIZALEZ
Credential	:	LCSW
Telephone Number	:	909-294-6353

Provider Enumeration Date	:	12/18/2023
Last Update Date	:	12/18/2023

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Directions to “MERCEDES CANIZALEZ ” Practice Location

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