Provider Demographics
NPI:1285162628
Name:VICTORIA, RAFAEL ENRICO (LCSW)
Entity type:Individual
Prefix:MR
First Name:RAFAEL
Middle Name:ENRICO
Last Name:VICTORIA
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:MR
Other - First Name:ERIC
Other - Middle Name:
Other - Last Name:VICTORIA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW
Mailing Address - Street 1:15050 IMPERIAL HWY
Mailing Address - Street 2:
Mailing Address - City:LA MIRADA
Mailing Address - State:CA
Mailing Address - Zip Code:90638-1301
Mailing Address - Country:US
Mailing Address - Phone:562-698-0811
Mailing Address - Fax:
Practice Address - Street 1:15050 IMPERIAL HWY
Practice Address - Street 2:
Practice Address - City:LA MIRADA
Practice Address - State:CA
Practice Address - Zip Code:90638-1301
Practice Address - Country:US
Practice Address - Phone:562-698-0811
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-30
Last Update Date:2017-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA275151041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA27515OtherLCSW