Provider Demographics
NPI:1669052759
Name:MAYORGA, DENISE JULIETTE
Entity type:Individual
Prefix:
First Name:DENISE
Middle Name:JULIETTE
Last Name:MAYORGA
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 1:19848 WELBY WAY
Mailing Address - Street 2:
Mailing Address - City:WINNETKA
Mailing Address - State:CA
Mailing Address - Zip Code:91306-4341
Mailing Address - Country:US
Mailing Address - Phone:818-312-6455
Mailing Address - Fax:
Practice Address - Street 1:19848 WELBY WAY
Practice Address - Street 2:
Practice Address - City:WINNETKA
Practice Address - State:CA
Practice Address - Zip Code:91306-4341
Practice Address - Country:US
Practice Address - Phone:818-312-6455
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-12
Last Update Date:2021-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician