Healthcare Provider Details

I. General information

NPI: 1861952087
Provider Name (Legal Business Name): ERNESTO MAYORGA MAYORGA LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/22/2019
Last Update Date: 12/17/2025
Certification Date: 12/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12500 BRUCEVILLE RD
ELK GROVE CA
95757-9784
US

IV. Provider business mailing address

PO BOX 690313
STOCKTON CA
95269-0313
US

V. Phone/Fax

Practice location:
  • Phone: 916-874-1927
  • Fax: 916-854-8911
Mailing address:
  • Phone: 916-874-1975
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number106945
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: