Provider Demographics
NPI:1013426790
Name:MENDEZ, DEJA NICOLE
Entity Type:Individual
Prefix:
First Name:DEJA
Middle Name:NICOLE
Last Name:MENDEZ
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 1:2213 PASEO DE TERCERO
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87507-8128
Mailing Address - Country:US
Mailing Address - Phone:505-310-1326
Mailing Address - Fax:
Practice Address - Street 1:2213 PASEO DE TERCERO
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87507
Practice Address - Country:US
Practice Address - Phone:505-310-1326
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-25
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician