Provider Demographics
NPI:1255091120
Name:AMEZCUA, MAYRA VERONICA
Entity type:Individual
Prefix:
First Name:MAYRA
Middle Name:VERONICA
Last Name:AMEZCUA
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 1:18249 HALSTED ST
Mailing Address - Street 2:
Mailing Address - City:NORTHRIDGE
Mailing Address - State:CA
Mailing Address - Zip Code:91325-1726
Mailing Address - Country:US
Mailing Address - Phone:805-421-3727
Mailing Address - Fax:
Practice Address - Street 1:840 N AVENUE 66
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90042-1508
Practice Address - Country:US
Practice Address - Phone:626-395-7100
Practice Address - Fax:626-395-7270
Is Sole Proprietor?:No
Enumeration Date:2021-12-20
Last Update Date:2023-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA96842104100000X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No104100000XBehavioral Health & Social Service ProvidersSocial Worker