Provider Demographics
NPI:1821561168
Name:MENDEZ, LYDIA ANN (SAC-IT)
Entity Type:Individual
Prefix:
First Name:LYDIA
Middle Name:ANN
Last Name:MENDEZ
Suffix:
Gender:F
Credentials:SAC-IT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1730 W WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53204-2066
Mailing Address - Country:US
Mailing Address - Phone:262-501-5962
Mailing Address - Fax:
Practice Address - Street 1:3703 N RICHARDS ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53212
Practice Address - Country:US
Practice Address - Phone:414-967-7006
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-09
Last Update Date:2019-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X
WI18748-130101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)