Provider Demographics
NPI:1992234579
Name:MENDOZA, AMANDA
Entity type:Individual
Prefix:
First Name:AMANDA
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 1:392 10TH ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11215-4009
Mailing Address - Country:US
Mailing Address - Phone:646-226-7615
Mailing Address - Fax:
Practice Address - Street 1:392 10TH ST # 3
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11215-4009
Practice Address - Country:US
Practice Address - Phone:646-226-7615
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-07
Last Update Date:2024-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
MA13080101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health