Provider Demographics
NPI:1801344296
Name:MENDOZA, GRACE (MSC, LPC)
Entity type:Individual
Prefix:
First Name:GRACE
Middle Name:
Last Name:MENDOZA
Suffix:
Gender:F
Credentials:MSC, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1180 W DESERT SEASONS DR
Mailing Address - Street 2:
Mailing Address - City:SAN TAN VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:85143-3438
Mailing Address - Country:US
Mailing Address - Phone:480-390-9811
Mailing Address - Fax:
Practice Address - Street 1:1180 W DESERT SEASONS DR
Practice Address - Street 2:
Practice Address - City:SAN TAN VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:85143-3438
Practice Address - Country:US
Practice Address - Phone:480-390-9811
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-14
Last Update Date:2021-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLAC-14449251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ18085OtherLICENSURE NUMBER