Provider Demographics
NPI:1639717390
Name:CHICO, MARIO
Entity Type:Individual
Prefix:MR
First Name:MARIO
Middle Name:
Last Name:CHICO
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 1:1245 E WALNUT ST
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91106-1878
Mailing Address - Country:US
Mailing Address - Phone:626-773-4364
Mailing Address - Fax:626-795-0979
Practice Address - Street 1:1245 E WALNUT ST
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91106-1878
Practice Address - Country:US
Practice Address - Phone:626-773-4364
Practice Address - Fax:626-795-0979
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-12
Last Update Date:2019-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA13592-R101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)