Provider Demographics
NPI:1184004368
Name:CERVANTES, MIRNA (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:MIRNA
Middle Name:
Last Name:CERVANTES
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1122
Mailing Address - Street 2:
Mailing Address - City:CULVER CITY
Mailing Address - State:CA
Mailing Address - Zip Code:90232-1122
Mailing Address - Country:US
Mailing Address - Phone:310-936-3308
Mailing Address - Fax:
Practice Address - Street 1:5183 OVERLAND AVE STE C
Practice Address - Street 2:
Practice Address - City:CULVER CITY
Practice Address - State:CA
Practice Address - Zip Code:90230-4990
Practice Address - Country:US
Practice Address - Phone:310-936-3308
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-03
Last Update Date:2019-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS295311041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical