Provider Demographics
NPI:1215435425
Name:MENDOZA, VICTOR HUGO
Entity type:Individual
Prefix:
First Name:VICTOR
Middle Name:HUGO
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 1:700 CARRIE AVE
Mailing Address - Street 2:
Mailing Address - City:ROCHELLE
Mailing Address - State:IL
Mailing Address - Zip Code:61068-1153
Mailing Address - Country:US
Mailing Address - Phone:815-501-2088
Mailing Address - Fax:
Practice Address - Street 1:4623 CRESCENT DRIVE
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61108-6110
Practice Address - Country:US
Practice Address - Phone:630-414-3036
Practice Address - Fax:630-414-3036
Is Sole Proprietor?:No
Enumeration Date:2018-01-23
Last Update Date:2024-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180011320101YP2500X
IL180.011320101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health