Provider Demographics
NPI:1104393859
Name:MENDOZA, GENESIS MARIAN
Entity Type:Individual
Prefix:
First Name:GENESIS
Middle Name:MARIAN
Last Name:MENDOZA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10200 NW 25TH ST STE 211
Mailing Address - Street 2:
Mailing Address - City:DORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33172-5927
Mailing Address - Country:US
Mailing Address - Phone:786-269-3502
Mailing Address - Fax:
Practice Address - Street 1:10200 NW 25TH ST STE 211
Practice Address - Street 2:
Practice Address - City:DORAL
Practice Address - State:FL
Practice Address - Zip Code:33172-5927
Practice Address - Country:US
Practice Address - Phone:786-269-3502
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-31
Last Update Date:2018-12-14
Deactivation Date:2018-11-12
Deactivation Code:
Reactivation Date:2018-12-12
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst