Provider Demographics
NPI:1750717526
Name:MENDOZA, MARIO (MFT)
Entity type:Individual
Prefix:
First Name:MARIO
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 1:320 MCCOMBS STE. C
Mailing Address - Street 2:
Mailing Address - City:CHAPARRAL
Mailing Address - State:NM
Mailing Address - Zip Code:88081
Mailing Address - Country:US
Mailing Address - Phone:575-882-5100
Mailing Address - Fax:575-882-1151
Practice Address - Street 1:320 MCCOMBS RD STE C
Practice Address - Street 2:
Practice Address - City:CHAPARRAL
Practice Address - State:NM
Practice Address - Zip Code:88081-7937
Practice Address - Country:US
Practice Address - Phone:575-882-5100
Practice Address - Fax:575-882-1151
Is Sole Proprietor?:No
Enumeration Date:2013-09-24
Last Update Date:2013-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMT-0160991106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM64153274Medicaid