Provider Demographics
NPI:1164207429
Name:MANSOOR, ESMERALDA R
Entity Type:Individual
Prefix:
First Name:ESMERALDA
Middle Name:R
Last Name:MANSOOR
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ESMERALDA
Other - Middle Name:
Other - Last Name:RENTERIA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:11957 MIRO CIR
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92131-3326
Mailing Address - Country:US
Mailing Address - Phone:562-716-6151
Mailing Address - Fax:
Practice Address - Street 1:11957 MIRO CIR
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92131-3326
Practice Address - Country:US
Practice Address - Phone:562-716-6151
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-25
Last Update Date:2023-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX71905103TS0200X
CA190146765103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool