Provider Demographics
NPI:1255957973
Name:MORA, MARIO (SUDRC)
Entity type:Individual
Prefix:MR
First Name:MARIO
Middle Name:
Last Name:MORA
Suffix:
Gender:M
Credentials:SUDRC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7320 EXETER ST APT 5
Mailing Address - Street 2:
Mailing Address - City:PARAMOUNT
Mailing Address - State:CA
Mailing Address - Zip Code:90723-3333
Mailing Address - Country:US
Mailing Address - Phone:562-469-2757
Mailing Address - Fax:
Practice Address - Street 1:5723 WHITTIER BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90022-4222
Practice Address - Country:US
Practice Address - Phone:323-721-6855
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-18
Last Update Date:2020-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10482101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty