Provider Demographics
NPI:1497339022
Name:MENDOZA, JOSE ANGEL (LCDC)
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:ANGEL
Last Name:MENDOZA
Suffix:
Gender:M
Credentials:LCDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4054 MCKINNEY AVE STE 102
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75204-2050
Mailing Address - Country:US
Mailing Address - Phone:214-520-6308
Mailing Address - Fax:214-521-9172
Practice Address - Street 1:4054 MCKINNEY AVE STE 102
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75204-2050
Practice Address - Country:US
Practice Address - Phone:214-520-6308
Practice Address - Fax:214-521-9172
Is Sole Proprietor?:No
Enumeration Date:2021-05-10
Last Update Date:2021-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX84859101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)