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General NPI Number Information
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NPI Number | 1336933423
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Entity Type | Individual
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Provider Name | SELENA MAYORGA
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Gender | Female
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Dates
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Enumeration Date | 04/05/2025
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Last Update Date | 04/05/2025
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Provider Practice Location Address
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Address Line | 2316 S DAMEN AVE
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City | CHICAGO
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State | IL
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Zip | 60608-4210
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Country | US
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Telephone | 708-504-6809
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Fax |
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Provider Business Mailing Address
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Address Line | 5043 W 23RD ST
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City | CICERO
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State | IL
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Zip | 60804-2928
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Country | US
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Telephone | 708-504-6809
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 104100000X
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Taxonomy Name | Social Worker
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License Number |
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License Number State |
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