Provider Demographics
NPI:1396360301
Name:MENDIOLA, ERIK M
Entity Type:Individual
Prefix:
First Name:ERIK
Middle Name:M
Last Name:MENDIOLA
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 1:223 W I ST
Mailing Address - Street 2:
Mailing Address - City:SHELTON
Mailing Address - State:WA
Mailing Address - Zip Code:98584-2923
Mailing Address - Country:US
Mailing Address - Phone:360-463-7065
Mailing Address - Fax:
Practice Address - Street 1:223 W I ST
Practice Address - Street 2:
Practice Address - City:SHELTON
Practice Address - State:WA
Practice Address - Zip Code:98584-2923
Practice Address - Country:US
Practice Address - Phone:360-463-7065
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-15
Last Update Date:2020-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103K00000X
WA103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst