Provider Demographics
NPI:1437552197
Name:MENDOZA, EDY MARIE (2013008645)
Entity Type:Individual
Prefix:
First Name:EDY
Middle Name:MARIE
Last Name:MENDOZA
Suffix:
Gender:F
Credentials:2013008645
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:339 ELMWOOD ESTATES DR
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:MO
Mailing Address - Zip Code:63090-5497
Mailing Address - Country:US
Mailing Address - Phone:636-485-3528
Mailing Address - Fax:636-239-1931
Practice Address - Street 1:339 ELMWOOD ESTATES DR
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:MO
Practice Address - Zip Code:63090-5497
Practice Address - Country:US
Practice Address - Phone:636-485-3528
Practice Address - Fax:636-239-1931
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-08
Last Update Date:2014-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2013008645101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional