Provider Demographics
NPI:1619627551
Name:MENDOZA, LISA D (LPCC)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:D
Last Name:MENDOZA
Suffix:
Gender:F
Credentials:LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3335 BUCHANAN ST NE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55418-1449
Mailing Address - Country:US
Mailing Address - Phone:651-263-4149
Mailing Address - Fax:
Practice Address - Street 1:3335 BUCHANAN ST NE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55418-1449
Practice Address - Country:US
Practice Address - Phone:651-263-4149
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-24
Last Update Date:2024-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN103TC2200X
101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent