Provider Demographics
NPI:1558989855
Name:MENDIBURU, GLORIA AIDA (MD)
Entity Type:Individual
Prefix:
First Name:GLORIA
Middle Name:AIDA
Last Name:MENDIBURU
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11608 TOMAHAWK CREEK PKWY APT C
Mailing Address - Street 2:
Mailing Address - City:LEAWOOD
Mailing Address - State:KS
Mailing Address - Zip Code:66211-2625
Mailing Address - Country:US
Mailing Address - Phone:913-748-5798
Mailing Address - Fax:
Practice Address - Street 1:6420 W 95TH ST STE 100
Practice Address - Street 2:
Practice Address - City:OVERLAND PARK
Practice Address - State:KS
Practice Address - Zip Code:66212-1434
Practice Address - Country:US
Practice Address - Phone:913-826-3150
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-13
Last Update Date:2020-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS3611101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty