Provider Demographics
NPI:1447768288
Name:MENDOZA, ROSALILIA M
Entity Type:Individual
Prefix:
First Name:ROSALILIA
Middle Name:M
Last Name:MENDOZA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6400 LAUREL CANYON BLVD STE 500
Mailing Address - Street 2:
Mailing Address - City:NORTH HOLLYWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:91606-1562
Mailing Address - Country:US
Mailing Address - Phone:818-901-6376
Mailing Address - Fax:
Practice Address - Street 1:6400 LAUREL CANYON BLVD STE 500
Practice Address - Street 2:
Practice Address - City:NORTH HOLLYWOOD
Practice Address - State:CA
Practice Address - Zip Code:91606-1562
Practice Address - Country:US
Practice Address - Phone:818-901-6376
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-15
Last Update Date:2018-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101YM0800X
CA3183101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health