Provider Demographics
NPI:1497181234
Name:MENDOZA, ISSAC MICHAEL
Entity Type:Individual
Prefix:
First Name:ISSAC
Middle Name:MICHAEL
Last Name:MENDOZA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1320 DAWLEY ST
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89104-5512
Mailing Address - Country:US
Mailing Address - Phone:702-689-2471
Mailing Address - Fax:
Practice Address - Street 1:1320 DAWLEY ST
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89104-5512
Practice Address - Country:US
Practice Address - Phone:702-689-2471
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-25
Last Update Date:2013-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV302Medicaid