Provider Demographics
NPI:1881339612
Name:MERCADO, GEORGE
Entity type:Individual
Prefix:
First Name:GEORGE
Middle Name:
Last Name:MERCADO
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 1:4221 WILSHIRE BLVD STE 300A
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90010-3537
Mailing Address - Country:US
Mailing Address - Phone:888-428-3223
Mailing Address - Fax:323-866-1881
Practice Address - Street 1:1149 W 190TH ST STE 2200
Practice Address - Street 2:
Practice Address - City:GARDENA
Practice Address - State:CA
Practice Address - Zip Code:90248-4344
Practice Address - Country:US
Practice Address - Phone:310-856-0800
Practice Address - Fax:855-568-2494
Is Sole Proprietor?:No
Enumeration Date:2022-05-05
Last Update Date:2023-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA103K00000X
103K00000X, 106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst