Provider Demographics
NPI:1619748894
Name:MENDOZA, BRIAN-TATE ANGELES
Entity Type:Individual
Prefix:
First Name:BRIAN-TATE
Middle Name:ANGELES
Last Name:MENDOZA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33464 SCHOENHERR RD
Mailing Address - Street 2:
Mailing Address - City:STERLING HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48312-6314
Mailing Address - Country:US
Mailing Address - Phone:586-999-5971
Mailing Address - Fax:
Practice Address - Street 1:33464 SCHOENHERR RD
Practice Address - Street 2:
Practice Address - City:STERLING HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48312-6314
Practice Address - Country:US
Practice Address - Phone:586-999-5971
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-16
Last Update Date:2024-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician