Provider Demographics
NPI:1912539644
Name:MENDOZA- DIAZ, ALEJANDRA
Entity Type:Individual
Prefix:
First Name:ALEJANDRA
Middle Name:
Last Name:MENDOZA- DIAZ
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 1:4131 DURANGO AVE
Mailing Address - Street 2:
Mailing Address - City:SEBRING
Mailing Address - State:FL
Mailing Address - Zip Code:33872-1562
Mailing Address - Country:US
Mailing Address - Phone:863-257-4786
Mailing Address - Fax:
Practice Address - Street 1:4131 DURANGO AVE
Practice Address - Street 2:
Practice Address - City:SEBRING
Practice Address - State:FL
Practice Address - Zip Code:33872-1562
Practice Address - Country:US
Practice Address - Phone:863-257-4786
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-11
Last Update Date:2020-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-19-108723103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst