Provider Demographics
NPI:1952955049
Name:MENDOZA, PRISCILA
Entity Type:Individual
Prefix:
First Name:PRISCILA
Middle Name:
Last Name:MENDOZA
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 1:4094 ELDERBERRY RDG
Mailing Address - Street 2:
Mailing Address - City:LAKE ELSINORE
Mailing Address - State:CA
Mailing Address - Zip Code:92530-2043
Mailing Address - Country:US
Mailing Address - Phone:626-510-5303
Mailing Address - Fax:
Practice Address - Street 1:4094 ELDERBERRY RDG
Practice Address - Street 2:
Practice Address - City:LAKE ELSINORE
Practice Address - State:CA
Practice Address - Zip Code:92530-2043
Practice Address - Country:US
Practice Address - Phone:626-510-5303
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-28
Last Update Date:2023-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALMFT138411106H00000X
CAAMFT113170106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist