Provider Demographics
NPI:1689148231
Name:MENDOZA, SOPHIA ELENA
Entity Type:Individual
Prefix:
First Name:SOPHIA
Middle Name:ELENA
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 1:15808 HESPERIAN BLVD UNIT 914
Mailing Address - Street 2:
Mailing Address - City:SAN LORENZO
Mailing Address - State:CA
Mailing Address - Zip Code:94580-5064
Mailing Address - Country:US
Mailing Address - Phone:510-909-5299
Mailing Address - Fax:
Practice Address - Street 1:243 CARINA DR
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95401
Practice Address - Country:US
Practice Address - Phone:510-909-5299
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-16
Last Update Date:2023-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA118725106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist