Provider Demographics
NPI:1528410602
Name:MAYORGA, VANESSA CHARLENE (MSW)
Entity Type:Individual
Prefix:MS
First Name:VANESSA
Middle Name:CHARLENE
Last Name:MAYORGA
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1301 5TH AVE
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10029-3119
Mailing Address - Country:US
Mailing Address - Phone:510-387-3809
Mailing Address - Fax:
Practice Address - Street 1:1301 5TH AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10029-3119
Practice Address - Country:US
Practice Address - Phone:510-387-3809
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-12
Last Update Date:2016-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY093727-1104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker