MEDICARE: JUAN MANUEL PLASCENCIA LIZAOLA JR. ASSOCIATE CLINICAL

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	113155	CA

General Provider Information

NPI Number	:	1053024695
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JUAN MANUEL PLASCENCIA LIZAOLA JR. ASSOCIATE CLINICAL

Provider Business Mailing Address
First Line	:	643 GATES CT
Second Line	:
City	:	PASO ROBLES
State	:	CA
Zip	:	93446-2718
Country	:	US
Telephone Number	:	805-835-9005
Fax Number	:	805-788-2724

Provider Business Practice Location Address
First Line	:	805 4TH ST
Second Line	:
City	:	PASO ROBLES
State	:	CA
Zip	:	93446-3173
Country	:	US
Telephone Number	:	805-226-3262
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/28/2022
Last Update Date	:	07/25/2025

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