Healthcare Provider Details

I. General information

NPI: 1891266367
Provider Name (Legal Business Name): HERSON MOJICA PSYCHOLOGIST
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/10/2018
Last Update Date: 12/10/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

920 E BROADWAY
GLENDALE CA
91205-1204
US

IV. Provider business mailing address

920 E BROADWAY
GLENDALE CA
91205-1204
US

V. Phone/Fax

Practice location:
  • Phone: 818-242-9481
  • Fax:
Mailing address:
  • Phone: 818-242-9681
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number2012909
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: