Provider Demographics
NPI:1376323857
Name:MENDOZA, MAIRA (LGPC200001626)
Entity Type:Individual
Prefix:
First Name:MAIRA
Middle Name:
Last Name:MENDOZA
Suffix:
Gender:F
Credentials:LGPC200001626
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:810 KENNEDY ST NW APT 205
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20011-2947
Mailing Address - Country:US
Mailing Address - Phone:202-413-6647
Mailing Address - Fax:
Practice Address - Street 1:2831 15TH ST NW
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20009-4607
Practice Address - Country:US
Practice Address - Phone:202-413-6647
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-03
Last Update Date:2023-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCLGPC200001626101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional