Provider Demographics
NPI:1164896742
Name:WILLARD, MIA GRAJEDA (LCSW)
Entity type:Individual
Prefix:
First Name:MIA
Middle Name:GRAJEDA
Last Name:WILLARD
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:PO BOX 2615
Mailing Address - Street 2:
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92628-2615
Mailing Address - Country:US
Mailing Address - Phone:714-394-3351
Mailing Address - Fax:
Practice Address - Street 1:3551 CAMINO MIRA COSTA STE T
Practice Address - Street 2:
Practice Address - City:SAN CLEMENTE
Practice Address - State:CA
Practice Address - Zip Code:92672-3508
Practice Address - Country:US
Practice Address - Phone:714-394-3351
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-19
Last Update Date:2025-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1157881041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical