Provider Demographics
NPI:1245756790
Name:MENDOZA, KATTYS ELENA
Entity Type:Individual
Prefix:
First Name:KATTYS
Middle Name:ELENA
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 1:3501 JACKSON STREET
Mailing Address - Street 2:209
Mailing Address - City:HOLLYWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:33021
Mailing Address - Country:US
Mailing Address - Phone:954-865-6334
Mailing Address - Fax:
Practice Address - Street 1:1001 W. CYPRESS CREEK RD.
Practice Address - Street 2:120
Practice Address - City:FT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33309
Practice Address - Country:US
Practice Address - Phone:855-832-6727
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-16
Last Update Date:2017-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL692573196Medicaid
FL691749696Medicaid