Healthcare Provider Details

I. General information

NPI: 1255109690
Provider Name (Legal Business Name): CORINA MAYORGA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/14/2023
Last Update Date: 10/24/2024
Certification Date: 10/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

43322 GINGHAM AVE
LANCASTER CA
93535-4576
US

IV. Provider business mailing address

44421 10TH ST W STE 1
LANCASTER CA
93534-3335
US

V. Phone/Fax

Practice location:
  • Phone: 661-874-4050
  • Fax:
Mailing address:
  • Phone: 818-996-1051
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberSUDRC16050
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: