Provider Demographics
NPI:1649422569
Name:MENDOZA, ALICIA LISETT
Entity Type:Individual
Prefix:
First Name:ALICIA
Middle Name:LISETT
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 1:1016 ORCHARD WAY
Mailing Address - Street 2:
Mailing Address - City:LIVINGSTON
Mailing Address - State:CA
Mailing Address - Zip Code:95334-9763
Mailing Address - Country:US
Mailing Address - Phone:209-918-5977
Mailing Address - Fax:
Practice Address - Street 1:100 POPLAR AVE
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95354-0510
Practice Address - Country:US
Practice Address - Phone:209-550-5869
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-10-22
Last Update Date:2018-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health