Provider Demographics
NPI:1205297256
Name:MENDEZ, KRISTEN (LICSW)
Entity type:Individual
Prefix:
First Name:KRISTEN
Middle Name:
Last Name:MENDEZ
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1157 3RD AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:WA
Mailing Address - Zip Code:98632-6007
Mailing Address - Country:US
Mailing Address - Phone:360-751-1112
Mailing Address - Fax:360-577-8879
Practice Address - Street 1:1157 3RD AVE STE 100
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:WA
Practice Address - Zip Code:98632-6007
Practice Address - Country:US
Practice Address - Phone:360-751-1112
Practice Address - Fax:360-577-8879
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-17
Last Update Date:2016-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALW601439741041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical