Provider Demographics
NPI:1093461519
Name:MENDOZA, MATTHEW GREGORY
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:GREGORY
Last Name:MENDOZA
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 1:2920 N ACADEMY BLVD STE 210
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80917-5369
Mailing Address - Country:US
Mailing Address - Phone:719-466-4809
Mailing Address - Fax:
Practice Address - Street 1:2920 N ACADEMY BLVD STE 210
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80917-5369
Practice Address - Country:US
Practice Address - Phone:719-466-4809
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-23
Last Update Date:2022-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician