Provider Demographics
NPI:1336933423
Name:MAYORGA, SELENA
Entity type:Individual
Prefix:
First Name:SELENA
Middle Name:
Last Name:MAYORGA
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5043 W 23RD ST
Mailing Address - Street 2:
Mailing Address - City:CICERO
Mailing Address - State:IL
Mailing Address - Zip Code:60804-2928
Mailing Address - Country:US
Mailing Address - Phone:708-504-6809
Mailing Address - Fax:
Practice Address - Street 1:2316 S DAMEN AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60608-4210
Practice Address - Country:US
Practice Address - Phone:708-504-6809
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-04-05
Last Update Date:2025-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker