Provider Demographics
NPI:1558824490
Name:ANDREWS-MENDOZA, ROBERT DAVID (LADC)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:DAVID
Last Name:ANDREWS-MENDOZA
Suffix:
Gender:M
Credentials:LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11901 CENTRAL PARK WAY UNIT 2327
Mailing Address - Street 2:
Mailing Address - City:MAPLE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55369-2664
Mailing Address - Country:US
Mailing Address - Phone:612-701-3084
Mailing Address - Fax:218-454-1083
Practice Address - Street 1:11901 CENTRAL PARK WAY UNIT 2327
Practice Address - Street 2:
Practice Address - City:MAPLE GROVE
Practice Address - State:MN
Practice Address - Zip Code:55369-2664
Practice Address - Country:US
Practice Address - Phone:612-701-3084
Practice Address - Fax:218-454-1083
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-08
Last Update Date:2021-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN305422101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)