Healthcare Provider Details

I. General information

NPI: 1023973559
Provider Name (Legal Business Name): JULIO PENALOZA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/17/2025
Last Update Date: 12/17/2025
Certification Date: 12/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1425 W MANCHESTER AVE STE A
LOS ANGELES CA
90047-5436
US

IV. Provider business mailing address

1425 W MANCHESTER AVE STE A
LOS ANGELES CA
90047-5436
US

V. Phone/Fax

Practice location:
  • Phone: 310-247-7400
  • Fax:
Mailing address:
  • Phone: 310-247-7400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number133991
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: