Provider Demographics
NPI:1619040797
Name:MENDOZA, CECILIA
Entity Type:Individual
Prefix:
First Name:CECILIA
Middle Name:
Last Name:MENDOZA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2050 FAIRMONT DR
Mailing Address - Street 2:
Mailing Address - City:SAN LEANDRO
Mailing Address - State:CA
Mailing Address - Zip Code:94578
Mailing Address - Country:US
Mailing Address - Phone:510-760-6611
Mailing Address - Fax:510-483-4277
Practice Address - Street 1:2050 FAIRMONT DR
Practice Address - Street 2:
Practice Address - City:SAN LEANDRO
Practice Address - State:CA
Practice Address - Zip Code:94578-1001
Practice Address - Country:US
Practice Address - Phone:510-760-6611
Practice Address - Fax:510-483-4277
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-16
Last Update Date:2013-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA294521041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1619040797Medicare PIN