Healthcare Provider Details

I. General information

NPI: 1609165265
Provider Name (Legal Business Name): AGLAED VERONICA MAYORGA PSYD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: AGLAED VERONICA SALAZAR PSYD

II. Dates (important events)

Enumeration Date: 04/05/2011
Last Update Date: 11/26/2025
Certification Date: 11/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5665 WILSHIRE BLVD # 1267
LOS ANGELES CA
90036-3710
US

IV. Provider business mailing address

5665 WILSHIRE BLVD # 1267
LOS ANGELES CA
90036-3710
US

V. Phone/Fax

Practice location:
  • Phone: 562-250-4452
  • Fax:
Mailing address:
  • Phone: 562-250-4452
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number32765
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number32765
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code103TF0000X
TaxonomyFamily Psychologist
License Number32765
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code103TF0200X
TaxonomyForensic Psychologist
License Number32765
License Number StateCA
# 5
Primary TaxonomyY
Taxonomy Code103TF0200X
TaxonomyForensic Psychologist
License Number
License Number StateNULL
# 6
Primary TaxonomyN
Taxonomy Code103TP2701X
TaxonomyGroup Psychotherapy Psychologist
License Number32765
License Number StateCA
# 7
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: