Basic Information
| Provider Information | |||||||||
| NPI: | 1043609787 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MENDOZA | ||||||||
| FirstName: | MICHELLE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2410 W SAINT GERTRUDE PL | ||||||||
| Address2: | |||||||||
| City: | SANTA ANA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 927044647 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5628653644 | ||||||||
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| Practice Location | |||||||||
| Address1: | 21520 PIONEER BLVD STE 110 | ||||||||
| Address2: | |||||||||
| City: | HAWAIIAN GARDENS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 907162604 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5628653644 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/19/2015 | ||||||||
| LastUpdateDate: | 01/19/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | ASW63126 | CA | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.