MEDICARE: DR. AURELIO ENRIQUEZ JR. LCSW, PSYD

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	LCS 24862	CA
2	103TC0700X	Clinical Psychologist	PSY-29785	CA

General Provider Information

NPI Number	:	1891810438
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. AURELIO ENRIQUEZ JR. LCSW, PSYD

Provider Business Mailing Address
First Line	:	9330 BASELINE RD STE 108
Second Line	:
City	:	RANCHO CUCAMONGA
State	:	CA
Zip	:	91701-5827
Country	:	US
Telephone Number	:	909-980-1000
Fax Number	:	866-880-1254

Provider Business Practice Location Address
First Line	:	9330 BASELINE RD STE 108
Second Line	:
City	:	RANCHO CUCAMONGA
State	:	CA
Zip	:	91701-5827
Country	:	US
Telephone Number	:	909-980-1000
Fax Number	:	866-880-1254

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

Provider Enumeration Date	:	03/20/2007
Last Update Date	:	03/27/2018

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