Provider Demographics
NPI:1154152379
Name:MENDOZA, MICHAEL ANDREW
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:ANDREW
Last Name:MENDOZA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:220 SUMMIT BLVD UNIT 402
Mailing Address - Street 2:
Mailing Address - City:BROOMFIELD
Mailing Address - State:CO
Mailing Address - Zip Code:80021-8272
Mailing Address - Country:US
Mailing Address - Phone:303-513-5630
Mailing Address - Fax:
Practice Address - Street 1:8791 WOLFF CT STE 230
Practice Address - Street 2:
Practice Address - City:WESTMINSTER
Practice Address - State:CO
Practice Address - Zip Code:80031-3693
Practice Address - Country:US
Practice Address - Phone:720-507-6710
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-09
Last Update Date:2024-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COLPCC.0019666101Y00000X
COLPC.0021157101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor