Provider Demographics
NPI:1871318204
Name:PENALOZA, MAYRA
Entity type:Individual
Prefix:
First Name:MAYRA
Middle Name:
Last Name:PENALOZA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1421 SALMON RIVER RD
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92501-1536
Mailing Address - Country:US
Mailing Address - Phone:951-505-2416
Mailing Address - Fax:
Practice Address - Street 1:12110 SLAUSON AVE STE 16
Practice Address - Street 2:
Practice Address - City:SANTA FE SPRINGS
Practice Address - State:CA
Practice Address - Zip Code:90670-8656
Practice Address - Country:US
Practice Address - Phone:323-524-9347
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-20
Last Update Date:2024-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA934591041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical