Provider Demographics
NPI:1275264657
Name:MENDIGOCHEA, NICOLE LEANNE
Entity Type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:LEANNE
Last Name:MENDIGOCHEA
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 1:11122 LANGLEY DR
Mailing Address - Street 2:
Mailing Address - City:LOS ALAMITOS
Mailing Address - State:CA
Mailing Address - Zip Code:90720-2630
Mailing Address - Country:US
Mailing Address - Phone:215-359-6982
Mailing Address - Fax:
Practice Address - Street 1:520 N LA BREA AVE
Practice Address - Street 2:
Practice Address - City:INGLEWOOD
Practice Address - State:CA
Practice Address - Zip Code:90302-3049
Practice Address - Country:US
Practice Address - Phone:323-294-4932
Practice Address - Fax:323-294-2533
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-17
Last Update Date:2022-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)