Provider Demographics
NPI:1578978680
Name:MENDOZA, MADISON (BCBS)
Entity Type:Individual
Prefix:MRS
First Name:MADISON
Middle Name:
Last Name:MENDOZA
Suffix:
Gender:F
Credentials:BCBS
Other - Prefix:
Other - First Name:MADISON
Other - Middle Name:
Other - Last Name:UMPHRES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BCBA
Mailing Address - Street 1:320 SIXTH ST
Mailing Address - Street 2:BASICS NW LLC
Mailing Address - City:RAYMOND
Mailing Address - State:WA
Mailing Address - Zip Code:98577
Mailing Address - Country:US
Mailing Address - Phone:360-915-6868
Mailing Address - Fax:360-515-5783
Practice Address - Street 1:320 SIXTH ST
Practice Address - Street 2:BASICS NW LLC
Practice Address - City:RAYMOND
Practice Address - State:WA
Practice Address - Zip Code:98577
Practice Address - Country:US
Practice Address - Phone:360-915-6868
Practice Address - Fax:360-515-5783
Is Sole Proprietor?:No
Enumeration Date:2014-06-26
Last Update Date:2024-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103K00000X
WA103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst