Healthcare Provider Details

I. General information

NPI: 1255091120
Provider Name (Legal Business Name): MAYRA VERONICA AMEZCUA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/20/2021
Last Update Date: 06/26/2023
Certification Date: 06/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

840 N AVENUE 66
LOS ANGELES CA
90042-1508
US

IV. Provider business mailing address

18249 HALSTED ST
NORTHRIDGE CA
91325-1726
US

V. Phone/Fax

Practice location:
  • Phone: 626-395-7100
  • Fax: 626-395-7270
Mailing address:
  • Phone: 805-421-3727
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number96842
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number96842
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: