MEDICARE: DR. AGLAED VERONICA MAYORGA PSYD

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	103TP2701X	Group Psychotherapy Psychologist	32765	CA
2	103TF0200X	Forensic Psychologist	32765	CA
3	103TF0200X	Forensic Psychologist
4	171M00000X	Case Manager/Care Coordinator
5	103TC0700X	Clinical Psychologist	32765	CA
6	103T00000X	Psychologist	32765	CA
7	103TF0000X	Family Psychologist	32765	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	15483734	OTHER	CA	CAQH
2	32765	OTHER	CA	PSY

General Provider Information

NPI Number	:	1609165265
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. AGLAED VERONICA MAYORGA PSYD

Provider Business Mailing Address
First Line	:	5665 WILSHIRE BLVD # 1267
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90036-3710
Country	:	US
Telephone Number	:	562-250-4452
Fax Number	:

Provider Business Practice Location Address
First Line	:	5665 WILSHIRE BLVD # 1267
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90036-3710
Country	:	US
Telephone Number	:	562-250-4452
Fax Number	:

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

Provider Enumeration Date	:	04/05/2011
Last Update Date	:	11/26/2025

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