Provider Demographics
NPI:1083834501
Name:MENDIVIL, JOSE
Entity Type:Individual
Prefix:MR
First Name:JOSE
Middle Name:
Last Name:MENDIVIL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7043 W PURDUE AVE
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85345-8857
Mailing Address - Country:US
Mailing Address - Phone:623-878-0436
Mailing Address - Fax:
Practice Address - Street 1:735 E FILLMORE ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85006-3324
Practice Address - Country:US
Practice Address - Phone:602-257-4851
Practice Address - Fax:602-257-4852
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-26
Last Update Date:2007-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ101YS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool