Provider Demographics
NPI:1194296749
Name:MENDIETA, ANAIS KINEYDA (LCSW, LCAS)
Entity type:Individual
Prefix:MRS
First Name:ANAIS
Middle Name:KINEYDA
Last Name:MENDIETA
Suffix:
Gender:F
Credentials:LCSW, LCAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3064 WAKE FOREST RD # 1223
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27609-7844
Mailing Address - Country:US
Mailing Address - Phone:910-920-5630
Mailing Address - Fax:
Practice Address - Street 1:5814 BLACKSMITH DR
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27606-7701
Practice Address - Country:US
Practice Address - Phone:910-920-5630
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-07
Last Update Date:2023-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCLCAS-25246101YA0400X
NCP0131281041C0700X
NCC0136501041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)