Provider Demographics
NPI:1306510094
Name:COCA, JUAN CARLOS
Entity type:Individual
Prefix:
First Name:JUAN
Middle Name:CARLOS
Last Name:COCA
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 1:1625 W OLYMPIC BLVD STE 6006TH
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90015-3809
Mailing Address - Country:US
Mailing Address - Phone:323-999-2404
Mailing Address - Fax:
Practice Address - Street 1:1625 W OLYMPIC BLVD STE 6006TH
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90015-3809
Practice Address - Country:US
Practice Address - Phone:323-999-2404
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-05
Last Update Date:2024-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAASW102289101YM0800X
CAACSW102289104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health