MEDICARE: MAYRA RUVALCABA GOMEZ LCSW

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	LCSW87570	CA

General Provider Information

NPI Number	:	1558762351
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MAYRA RUVALCABA GOMEZ LCSW

Provider Business Mailing Address
First Line	:	1120 W LA VETA AVE STE 660
Second Line	:
City	:	ORANGE
State	:	CA
Zip	:	92868-4244
Country	:	US
Telephone Number	:	714-583-6810
Fax Number	:

Provider Business Practice Location Address
First Line	:	1120 W LA VETA AVE STE 660
Second Line	:
City	:	ORANGE
State	:	CA
Zip	:	92868-4244
Country	:	US
Telephone Number	:	714-296-6921
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/11/2014
Last Update Date	:	11/03/2023

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