Provider Demographics
NPI:1659822831
Name:SELF, MARIATERESA MENDOZA (CMT, LMT)
Entity Type:Individual
Prefix:MRS
First Name:MARIATERESA
Middle Name:MENDOZA
Last Name:SELF
Suffix:
Gender:F
Credentials:CMT, LMT
Other - Prefix:
Other - First Name:TERRI
Other - Middle Name:
Other - Last Name:SELF
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1450 HICKORY ST
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95678-6707
Mailing Address - Country:US
Mailing Address - Phone:916-412-1152
Mailing Address - Fax:
Practice Address - Street 1:3000 ARDEN WAY
Practice Address - Street 2:SUITE 1-A
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95825-2000
Practice Address - Country:US
Practice Address - Phone:916-488-5560
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-21
Last Update Date:2016-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAPIM-912071390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA13848Medicaid