Healthcare Provider Details

I. General information

NPI: 1083452536
Provider Name (Legal Business Name): MAYRA A MEHRGUTH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2024
Last Update Date: 07/18/2024
Certification Date: 07/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1310 W STEWART DR STE 301
ORANGE CA
92868-3838
US

IV. Provider business mailing address

1310 W STEWART DR STE 301
ORANGE CA
92868-3838
US

V. Phone/Fax

Practice location:
  • Phone: 714-712-0711
  • Fax: 657-224-4781
Mailing address:
  • Phone: 714-712-0711
  • Fax: 657-224-4781

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberAMFT134059
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: