Healthcare Provider Details

I. General information

NPI: 1316460207
Provider Name (Legal Business Name): MARITZA AGUAYO ACSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/21/2017
Last Update Date: 08/17/2023
Certification Date: 08/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1635 W MAIN ST # 100
ALHAMBRA CA
91801
US

IV. Provider business mailing address

1635 W MAIN ST
ALHAMBRA CA
91801-1951
US

V. Phone/Fax

Practice location:
  • Phone: 626-248-1800
  • Fax:
Mailing address:
  • Phone: 626-248-1800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number83558
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberACSW83558
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberACSW83558
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: