Provider Demographics
NPI:1710623418
Name:SAUCEDO MENDEZ, FABIOLA
Entity type:Individual
Prefix:
First Name:FABIOLA
Middle Name:
Last Name:SAUCEDO MENDEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2463 E GALA ST STE 100
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-5210
Mailing Address - Country:US
Mailing Address - Phone:208-242-6522
Mailing Address - Fax:
Practice Address - Street 1:2463 E GALA ST STE 100
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-5210
Practice Address - Country:US
Practice Address - Phone:208-955-7333
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-06
Last Update Date:2025-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLMSW-408761041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty