Provider Demographics
NPI:1649824848
Name:MENDOZA, SANTANA (PEER SUPPORT SPECIAL)
Entity type:Individual
Prefix:
First Name:SANTANA
Middle Name:
Last Name:MENDOZA
Suffix:
Gender:F
Credentials:PEER SUPPORT SPECIAL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3465 MCNUTT RD
Mailing Address - Street 2:
Mailing Address - City:SUNLAND PARK
Mailing Address - State:NM
Mailing Address - Zip Code:88063-9056
Mailing Address - Country:US
Mailing Address - Phone:575-915-1338
Mailing Address - Fax:575-915-1819
Practice Address - Street 1:3465 MCNUTT RD
Practice Address - Street 2:
Practice Address - City:SUNLAND PARK
Practice Address - State:NM
Practice Address - Zip Code:88063-9056
Practice Address - Country:US
Practice Address - Phone:575-915-1338
Practice Address - Fax:575-915-1819
Is Sole Proprietor?:No
Enumeration Date:2019-07-26
Last Update Date:2019-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM2021175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM24256536Medicaid