Provider Demographics
NPI:1093124349
Name:MENDEZ, ANNE MARIE
Entity Type:Individual
Prefix:
First Name:ANNE
Middle Name:MARIE
Last Name:MENDEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ANNE
Other - Middle Name:MARIE
Other - Last Name:MENDEZ
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW, BSN
Mailing Address - Street 1:500 FAIRWAY DR STE 102
Mailing Address - Street 2:
Mailing Address - City:DEERFIELD BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33441-1817
Mailing Address - Country:US
Mailing Address - Phone:978-457-5523
Mailing Address - Fax:
Practice Address - Street 1:62 FOREST ST NE
Practice Address - Street 2:
Practice Address - City:LUDOWICI
Practice Address - State:GA
Practice Address - Zip Code:31316-7758
Practice Address - Country:US
Practice Address - Phone:978-457-5523
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-11
Last Update Date:2020-06-09
Deactivation Date:2020-02-05
Deactivation Code:
Reactivation Date:2020-06-09
Provider Licenses
StateLicense IDTaxonomies
222Q00000X
GACSW0070471041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist