Provider Demographics
NPI:1467583666
Name:MENDOZA, SAN JUANA (MAEDS)
Entity Type:Individual
Prefix:
First Name:SAN JUANA
Middle Name:
Last Name:MENDOZA
Suffix:
Gender:F
Credentials:MAEDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2968 S BROKEN ARROW LN
Mailing Address - Street 2:
Mailing Address - City:YUMA
Mailing Address - State:AZ
Mailing Address - Zip Code:85364-7447
Mailing Address - Country:US
Mailing Address - Phone:928-344-8096
Mailing Address - Fax:
Practice Address - Street 1:1453 N. MAIN STREET, SUITE F
Practice Address - Street 2:
Practice Address - City:SAL LUIS
Practice Address - State:AZ
Practice Address - Zip Code:85349
Practice Address - Country:US
Practice Address - Phone:928-627-3635
Practice Address - Fax:928-722-7025
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ333061OtherAHCCS