Provider Demographics
NPI:1851951735
Name:MENDOZA, IRVIN
Entity Type:Individual
Prefix:
First Name:IRVIN
Middle Name:
Last Name:MENDOZA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5201 TIETON DR STE C
Mailing Address - Street 2:
Mailing Address - City:YAKIMA
Mailing Address - State:WA
Mailing Address - Zip Code:98908-3485
Mailing Address - Country:US
Mailing Address - Phone:509-965-7100
Mailing Address - Fax:
Practice Address - Street 1:5201 TIETON DR
Practice Address - Street 2:
Practice Address - City:YAKIMA
Practice Address - State:WA
Practice Address - Zip Code:98908-3485
Practice Address - Country:US
Practice Address - Phone:509-965-7100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-13
Last Update Date:2019-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACB60975512106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Multi-Specialty