Basic Information
Provider Information | |||||||||
NPI: | 1285162628 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | VICTORIA | ||||||||
FirstName: | RAFAEL | ||||||||
MiddleName: | ENRICO | ||||||||
NamePrefix: | MR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | L.C.S.W. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | VICTORIA | ||||||||
OtherFirstName: | ERIC | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: | MR. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | L.C.S.W. | ||||||||
OtherLastNameType: | 2 | ||||||||
Mailing Information | |||||||||
Address1: | 15050 IMPERIAL HWY | ||||||||
Address2: |   | ||||||||
City: | LA MIRADA | ||||||||
State: | CA | ||||||||
PostalCode: | 906381301 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5626980811 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 15050 IMPERIAL HWY | ||||||||
Address2: |   | ||||||||
City: | LA MIRADA | ||||||||
State: | CA | ||||||||
PostalCode: | 906381301 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5626980811 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/30/2017 | ||||||||
LastUpdateDate: | 08/21/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 27515 | CA | Y |   | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
ID | Type | State | Issuer | Description | 27515 | 01 | CA | LCSW | OTHER |