Healthcare Provider Details

I. General information

NPI: 1184318073
Provider Name (Legal Business Name): ASHLEY N MAYORGA SUDRC I 25995
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/05/2023
Last Update Date: 09/15/2026
Certification Date: 09/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3499 10TH ST
RIVERSIDE CA
92501-3617
US

IV. Provider business mailing address

3499 10TH ST
RIVERSIDE CA
92501-3617
US

V. Phone/Fax

Practice location:
  • Phone: 951-358-4170
  • Fax:
Mailing address:
  • Phone: 951-617-1272
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberSUDRCI25995
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License NumberSUDRCI25995
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: