Healthcare Provider Details

I. General information

NPI: 1700501848
Provider Name (Legal Business Name): MAYRA F. CALATAYUD-GARCIA LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/11/2022
Last Update Date: 12/12/2023
Certification Date: 06/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

711 E VIA WANDA
LONG BEACH CA
90805-6526
US

IV. Provider business mailing address

PO BOX 4814
CULVER CITY CA
90231-4814
US

V. Phone/Fax

Practice location:
  • Phone: 562-380-1692
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW99515
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: