Provider Demographics
NPI:1467696567
Name:MENDIETA, GEMMA JACQUELINE (EDS)
Entity Type:Individual
Prefix:
First Name:GEMMA
Middle Name:JACQUELINE
Last Name:MENDIETA
Suffix:
Gender:F
Credentials:EDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5888 SW 27TH ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33155-3135
Mailing Address - Country:US
Mailing Address - Phone:305-662-4236
Mailing Address - Fax:
Practice Address - Street 1:5888 SW 27TH ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33155-3135
Practice Address - Country:US
Practice Address - Phone:305-662-4236
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-21
Last Update Date:2009-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSS791103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool