Provider Demographics
NPI:1205447166
Name:MENDEZ, AYLA VITALIA (MA)
Entity type:Individual
Prefix:
First Name:AYLA
Middle Name:VITALIA
Last Name:MENDEZ
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2430 WARRENTON RD
Mailing Address - Street 2:
Mailing Address - City:FREDERICKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:22406-4836
Mailing Address - Country:US
Mailing Address - Phone:540-322-8883
Mailing Address - Fax:
Practice Address - Street 1:23164 DRAGOON RD
Practice Address - Street 2:
Practice Address - City:LIGNUM
Practice Address - State:VA
Practice Address - Zip Code:22726-2036
Practice Address - Country:US
Practice Address - Phone:540-399-1926
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-13
Last Update Date:2020-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701009793101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional