Provider Demographics
NPI:1417302563
Name:MENDOZA, SANDRA BERENICE (LBSW)
Entity Type:Individual
Prefix:MRS
First Name:SANDRA
Middle Name:BERENICE
Last Name:MENDOZA
Suffix:
Gender:F
Credentials:LBSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:72 GAIL HARRIS ST
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:NM
Mailing Address - Zip Code:88203-8116
Mailing Address - Country:US
Mailing Address - Phone:575-347-3400
Mailing Address - Fax:575-347-3435
Practice Address - Street 1:72 GAIL HARRIS ST
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:NM
Practice Address - Zip Code:88203-8116
Practice Address - Country:US
Practice Address - Phone:575-347-3400
Practice Address - Fax:575-347-3435
Is Sole Proprietor?:No
Enumeration Date:2016-04-26
Last Update Date:2016-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMB-09441101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)