Provider Demographics
NPI:1659634012
Name:MENDOZA, DYANDA (DEA) LYN
Entity Type:Individual
Prefix:
First Name:DYANDA (DEA)
Middle Name:LYN
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 1:1502 CASTRO ST
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94114-3719
Mailing Address - Country:US
Mailing Address - Phone:650-823-2102
Mailing Address - Fax:415-282-2573
Practice Address - Street 1:1502 CASTRO ST
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94114-3719
Practice Address - Country:US
Practice Address - Phone:650-823-2102
Practice Address - Fax:415-282-2573
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-20
Last Update Date:2012-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1248225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1248OtherCALIFORNIA MASSAGE THERAPY ASSOCIATION