Provider Demographics
NPI:1508198839
Name:MENDOZA, CONRAD (MFT)
Entity Type:Individual
Prefix:
First Name:CONRAD
Middle Name:
Last Name:MENDOZA
Suffix:
Gender:M
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2178 JOHNSON AVE
Mailing Address - Street 2:
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93401-4535
Mailing Address - Country:US
Mailing Address - Phone:805-458-8401
Mailing Address - Fax:
Practice Address - Street 1:1989 VICENTE DR BLDG A
Practice Address - Street 2:
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93405-6863
Practice Address - Country:US
Practice Address - Phone:805-235-4696
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-02-11
Last Update Date:2014-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC53536106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist