Provider Demographics
NPI:1093047359
Name:MAYORGA, MARY G (PHD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:G
Last Name:MAYORGA
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:302 SALISBURY LN
Mailing Address - Street 2:
Mailing Address - City:VICTORIA
Mailing Address - State:TX
Mailing Address - Zip Code:77904-2204
Mailing Address - Country:US
Mailing Address - Phone:361-688-1424
Mailing Address - Fax:
Practice Address - Street 1:3904 JOHN STOCKBAUER DR
Practice Address - Street 2:#106
Practice Address - City:VICTORIA
Practice Address - State:TX
Practice Address - Zip Code:77904-2450
Practice Address - Country:US
Practice Address - Phone:361-688-1424
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-10
Last Update Date:2010-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX18031101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional