Provider Demographics
NPI:1700655024
Name:MENDOZA, SEBASTIEN XAVIER
Entity Type:Individual
Prefix:
First Name:SEBASTIEN
Middle Name:XAVIER
Last Name:MENDOZA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4830 W PENSACOLA AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60641-1509
Mailing Address - Country:US
Mailing Address - Phone:312-361-4154
Mailing Address - Fax:
Practice Address - Street 1:900 WAUKEGAN RD
Practice Address - Street 2:
Practice Address - City:GLENVIEW
Practice Address - State:IL
Practice Address - Zip Code:60025-4315
Practice Address - Country:US
Practice Address - Phone:331-229-8839
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-28
Last Update Date:2023-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILBACB1030287106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician