Provider Demographics
NPI:1205520160
Name:MENDOZA, IZAAC VICTOR (BA)
Entity type:Individual
Prefix:
First Name:IZAAC
Middle Name:VICTOR
Last Name:MENDOZA
Suffix:
Gender:M
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4590 S 20TH ST APT 4
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53221-5307
Mailing Address - Country:US
Mailing Address - Phone:773-558-9363
Mailing Address - Fax:
Practice Address - Street 1:200 PATRICK BLVD SUITE 250
Practice Address - Street 2:
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53045
Practice Address - Country:US
Practice Address - Phone:888-754-0398
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-05
Last Update Date:2023-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician