Healthcare Provider Details

I. General information

NPI: 1629484605
Provider Name (Legal Business Name): BRANDY SHAVON MAYS-CANCINO LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2014
Last Update Date: 11/13/2024
Certification Date: 11/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

31772 CASINO DR STE B
LAKE ELSINORE CA
92530-4502
US

IV. Provider business mailing address

29965 BERRYESSA DR
SUN CITY CA
92585-3510
US

V. Phone/Fax

Practice location:
  • Phone: 951-459-6227
  • Fax:
Mailing address:
  • Phone: 805-377-1951
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number103573
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number126644
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: