Provider Demographics
NPI:1588364673
Name:MUJICA, NICHOLAS EDWIN
Entity type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:EDWIN
Last Name:MUJICA
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 1:12437 LEWIS ST STE 100
Mailing Address - Street 2:
Mailing Address - City:GARDEN GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:92840-4651
Mailing Address - Country:US
Mailing Address - Phone:714-202-0118
Mailing Address - Fax:805-456-0666
Practice Address - Street 1:12437 LEWIS ST STE 100
Practice Address - Street 2:
Practice Address - City:GARDEN GROVE
Practice Address - State:CA
Practice Address - Zip Code:92840-4651
Practice Address - Country:US
Practice Address - Phone:714-202-0118
Practice Address - Fax:805-456-0666
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-07
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician