Provider Demographics
NPI:1538635412
Name:MAYORGA, JUDITH GABRIELA
Entity Type:Individual
Prefix:
First Name:JUDITH
Middle Name:GABRIELA
Last Name:MAYORGA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10200 NW 25TH ST # A-108
Mailing Address - Street 2:
Mailing Address - City:DORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33172-5921
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10200 NW 25TH ST # A-108
Practice Address - Street 2:
Practice Address - City:DORAL
Practice Address - State:FL
Practice Address - Zip Code:33172-5921
Practice Address - Country:US
Practice Address - Phone:305-767-1924
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-18
Last Update Date:2020-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSI43682355S0801X
FL18-65482106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician