Provider Demographics
NPI:1992815153
Name:MUCINO, GLORIA ELIZABETH (LCSW)
Entity type:Individual
Prefix:
First Name:GLORIA
Middle Name:ELIZABETH
Last Name:MUCINO
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12301 WILSHIRE BLVD
Mailing Address - Street 2:SUITE 210
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90025-1007
Mailing Address - Country:US
Mailing Address - Phone:310-826-8989
Mailing Address - Fax:310-391-1807
Practice Address - Street 1:12301 WILSHIRE BLVD
Practice Address - Street 2:SUITE 210
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90025-1007
Practice Address - Country:US
Practice Address - Phone:310-826-8989
Practice Address - Fax:310-391-1807
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2015-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS116811041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA11681OtherLICENSE
CASW11681AMedicare ID - Type Unspecified
CASW11681CMedicare ID - Type Unspecified