Provider Demographics
NPI:1639361017
Name:OSORIO, MIGUEL
Entity type:Individual
Prefix:MR
First Name:MIGUEL
Middle Name:
Last Name:OSORIO
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 1:1720 E 120TH ST
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90059-3052
Mailing Address - Country:US
Mailing Address - Phone:310-668-4793
Mailing Address - Fax:
Practice Address - Street 1:1720 E 120TH ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90059-3052
Practice Address - Country:US
Practice Address - Phone:310-668-4793
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-09
Last Update Date:2011-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS 276921041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical