Provider Demographics
NPI:1376066936
Name:GLAVEY MENDOZA, JOSE ISRAEL
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:ISRAEL
Last Name:GLAVEY 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 1:44550 VILLAGE CT STE 103
Mailing Address - Street 2:
Mailing Address - City:PALM DESERT
Mailing Address - State:CA
Mailing Address - Zip Code:92260-3817
Mailing Address - Country:US
Mailing Address - Phone:760-507-5502
Mailing Address - Fax:
Practice Address - Street 1:44550 VILLAGE CT STE 103
Practice Address - Street 2:
Practice Address - City:PALM DESERT
Practice Address - State:CA
Practice Address - Zip Code:92260-3817
Practice Address - Country:US
Practice Address - Phone:951-396-1395
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-25
Last Update Date:2024-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA13882101YP2500X
CA98030106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional