MEDICARE: MAYRA G CALDERON MFT

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	101YM0800X	Mental Health Counselor	43262	CA

General Provider Information

NPI Number	:	1265592836
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MAYRA G CALDERON MFT

Provider Business Mailing Address
First Line	:	2267 CALLE MARGARITA
Second Line	:
City	:	SAN DIMAS
State	:	CA
Zip	:	91773-4468
Country	:	US
Telephone Number	:	714-953-4455
Fax Number	:

Provider Business Practice Location Address
First Line	:	2267 CALLE MARGARITA
Second Line	:
City	:	SAN DIMAS
State	:	CA
Zip	:	91773-4468
Country	:	US
Telephone Number	:	714-953-4455
Fax Number	:

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

Provider Enumeration Date	:	12/12/2006
Last Update Date	:	07/08/2007

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