Healthcare Provider Details

I. General information

NPI: 1831669118
Provider Name (Legal Business Name): MAYRA OLASCUAGA R1328541118
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/29/2018
Last Update Date: 11/29/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3430 COGSWELL RD
EL MONTE CA
91732-2785
US

IV. Provider business mailing address

20700 SAN JOSE HILLS RD APT 26
WALNUT CA
91789-1304
US

V. Phone/Fax

Practice location:
  • Phone: 626-453-3406
  • Fax: 626-246-3433
Mailing address:
  • Phone: 442-230-8775
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberR1328541118
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: