Provider Demographics
NPI:1881020170
Name:MENDOZA, DENISSE PATRICIA
Entity Type:Individual
Prefix:
First Name:DENISSE
Middle Name:PATRICIA
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 1:4060 BENNETT VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95404-6237
Mailing Address - Country:US
Mailing Address - Phone:916-596-8636
Mailing Address - Fax:
Practice Address - Street 1:1360 N DUTTON AVE
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95401-4687
Practice Address - Country:US
Practice Address - Phone:707-569-0877
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-19
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101407106H00000X, 106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist