Provider Demographics
NPI:1124623327
Name:MAYORGADIAZ, IRENE (PSYCHIATRIC TECH)
Entity type:Individual
Prefix:
First Name:IRENE
Middle Name:
Last Name:MAYORGADIAZ
Suffix:
Gender:F
Credentials:PSYCHIATRIC TECH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:510 S VERMONT AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90020-1912
Mailing Address - Country:US
Mailing Address - Phone:213-407-4196
Mailing Address - Fax:
Practice Address - Street 1:2656 MUSCATEL AVE
Practice Address - Street 2:
Practice Address - City:ROSEMEAD
Practice Address - State:CA
Practice Address - Zip Code:91770
Practice Address - Country:US
Practice Address - Phone:760-373-0634
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-03
Last Update Date:2024-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA41284167G00000X
CAPT41284156F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes167G00000XNursing Service ProvidersLicensed Psychiatric Technician
No156F00000XEye and Vision Services ProvidersTechnician/Technologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPT41284OtherPSYCHIATRIC TECHNICIAN