Provider Demographics
NPI:1003667296
Name:DEGENNARO, MENDY KAY (B00003290224)
Entity Type:Individual
Prefix:
First Name:MENDY
Middle Name:KAY
Last Name:DEGENNARO
Suffix:
Gender:F
Credentials:B00003290224
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3647 40TH ST
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95817-3609
Mailing Address - Country:US
Mailing Address - Phone:916-452-1068
Mailing Address - Fax:916-452-1068
Practice Address - Street 1:3647 40TH ST
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95817-3609
Practice Address - Country:US
Practice Address - Phone:916-452-1068
Practice Address - Fax:916-469-9415
Is Sole Proprietor?:No
Enumeration Date:2024-03-27
Last Update Date:2024-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAB00003290224101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)