Healthcare Provider Details

I. General information

NPI: 1386809770
Provider Name (Legal Business Name): JUAN MAYORGA JR. LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/24/2008
Last Update Date: 02/13/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1975 LONG BEACH BLVD
LONG BEACH CA
90806-5501
US

IV. Provider business mailing address

1975 LONG BEACH BLVD
LONG BEACH CA
90806-5501
US

V. Phone/Fax

Practice location:
  • Phone: 562-215-1462
  • Fax:
Mailing address:
  • Phone: 562-215-1462
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW64891
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: