Provider Demographics
NPI:1528371358
Name:LOPEZ-MENDIOLA, ELISIA (LCSW, QMHP)
Entity Type:Individual
Prefix:
First Name:ELISIA
Middle Name:
Last Name:LOPEZ-MENDIOLA
Suffix:
Gender:F
Credentials:LCSW, QMHP
Other - Prefix:
Other - First Name:FELIZA
Other - Middle Name:
Other - Last Name:LOPEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSW, QMHP
Mailing Address - Street 1:12121 E BURNSIDE ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97216-3737
Mailing Address - Country:US
Mailing Address - Phone:971-361-7764
Mailing Address - Fax:
Practice Address - Street 1:12121 E BURNSIDE ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97216-3737
Practice Address - Country:US
Practice Address - Phone:971-361-7764
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-21
Last Update Date:2019-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X, 390200000X
ORL8223101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program