Basic Information
| Provider Information | |||||||||
| NPI: | 1235773839 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MUNDACA | ||||||||
| FirstName: | GRESIA | ||||||||
| MiddleName: | SOTO | ||||||||
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| Credential: | ACSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8337 TELEGRAPH RD STE 300 | ||||||||
| Address2: | |||||||||
| City: | PICO RIVERA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 906604957 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5628653644 | ||||||||
| FaxNumber: | 5622465704 | ||||||||
| Practice Location | |||||||||
| Address1: | 8337 TELEGRAPH RD STE 300 | ||||||||
| Address2: | |||||||||
| City: | PICO RIVERA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 906604957 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5628653644 | ||||||||
| FaxNumber: | 5622465704 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/06/2019 | ||||||||
| LastUpdateDate: | 11/10/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 11/10/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 91699 | CA | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.