Provider Demographics
NPI:1376174466
Name:MAYEN, NELSON
Entity Type:Individual
Prefix:
First Name:NELSON
Middle Name:
Last Name:MAYEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9650 ZELZAH AVE
Mailing Address - Street 2:
Mailing Address - City:NORTHRIDGE
Mailing Address - State:CA
Mailing Address - Zip Code:91325-2003
Mailing Address - Country:US
Mailing Address - Phone:818-993-9311
Mailing Address - Fax:
Practice Address - Street 1:9119 HASKELL AVE
Practice Address - Street 2:
Practice Address - City:NORTH HILLS
Practice Address - State:CA
Practice Address - Zip Code:91343-3121
Practice Address - Country:US
Practice Address - Phone:818-739-5900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-28
Last Update Date:2020-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAMFT117432106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist