Provider Demographics
NPI:1821731878
Name:MENDOTA, AMELIA (LSW, PMH-C, CD/BDT)
Entity Type:Individual
Prefix:
First Name:AMELIA
Middle Name:
Last Name:MENDOTA
Suffix:
Gender:F
Credentials:LSW, PMH-C, CD/BDT
Other - Prefix:
Other - First Name:MOLLY
Other - Middle Name:
Other - Last Name:MENDOTA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LSW, PMH-C, CD/BDT
Mailing Address - Street 1:401 E ALLEN ST
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47401-5915
Mailing Address - Country:US
Mailing Address - Phone:812-272-7278
Mailing Address - Fax:
Practice Address - Street 1:2613 E 3RD ST
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47401-5345
Practice Address - Country:US
Practice Address - Phone:812-727-0134
Practice Address - Fax:812-245-1118
Is Sole Proprietor?:No
Enumeration Date:2022-04-18
Last Update Date:2024-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
374J00000X
IN33011813A104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No374J00000XNursing Service Related ProvidersDoula