Provider Demographics
NPI:1659763324
Name:MENDOZA, KATIE (BA)
Entity Type:Individual
Prefix:
First Name:KATIE
Middle Name:
Last Name:MENDOZA
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4246 MILL CREEK ST
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92509
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1720 N 62ND ST
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68505-1202
Practice Address - Country:US
Practice Address - Phone:951-347-4039
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-04
Last Update Date:2022-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health