Provider Demographics
NPI:1154853877
Name:MENDES, MANUEL III
Entity Type:Individual
Prefix:
First Name:MANUEL
Middle Name:
Last Name:MENDES
Suffix:III
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 1:90 ELM HILL AVE
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02121-1747
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1100 WASHINGTON ST
Practice Address - Street 2:SUITE 206
Practice Address - City:DORCHESTER
Practice Address - State:MA
Practice Address - Zip Code:02124-1747
Practice Address - Country:US
Practice Address - Phone:617-325-2993
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-31
Last Update Date:2017-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health