Provider Demographics
NPI:1437824463
Name:MAYORAL, VICTOR E
Entity Type:Individual
Prefix:
First Name:VICTOR
Middle Name:E
Last Name:MAYORAL
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 1:266 N DOMINGUEZ PL
Mailing Address - Street 2:
Mailing Address - City:AZUSA
Mailing Address - State:CA
Mailing Address - Zip Code:91702-3715
Mailing Address - Country:US
Mailing Address - Phone:209-402-7558
Mailing Address - Fax:
Practice Address - Street 1:536 S 2ND AVE STE F
Practice Address - Street 2:
Practice Address - City:COVINA
Practice Address - State:CA
Practice Address - Zip Code:91723-3043
Practice Address - Country:US
Practice Address - Phone:626-966-1577
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-11
Last Update Date:2022-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CA130206106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program