Provider Demographics
NPI:1770604530
Name:MENDOZA-BONEWITS, ALICIA PATRICIA
Entity type:Individual
Prefix:
First Name:ALICIA
Middle Name:PATRICIA
Last Name:MENDOZA-BONEWITS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ALICIA
Other - Middle Name:PATRICIA
Other - Last Name:MENDOZA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD
Mailing Address - Street 1:132 PIN OAK FOREST ST
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78232-2002
Mailing Address - Country:US
Mailing Address - Phone:210-497-5602
Mailing Address - Fax:
Practice Address - Street 1:132 PIN OAK FOREST ST
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78232-2002
Practice Address - Country:US
Practice Address - Phone:210-497-5602
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX22784103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX097135002Medicaid
TX097135002Medicaid