Provider Demographics
NPI:1205502481
Name:MOGENSEN, ALEXANDER
Entity type:Individual
Prefix:
First Name:ALEXANDER
Middle Name:
Last Name:MOGENSEN
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 1:25910 ACERO STE 160
Mailing Address - Street 2:
Mailing Address - City:MISSION VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92691-2777
Mailing Address - Country:US
Mailing Address - Phone:909-268-3014
Mailing Address - Fax:
Practice Address - Street 1:34324 YUCAIPA BLVD STE B-C
Practice Address - Street 2:
Practice Address - City:YUCAIPA
Practice Address - State:CA
Practice Address - Zip Code:92399-2496
Practice Address - Country:US
Practice Address - Phone:909-268-3014
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-18
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
CA13093101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health