Provider Demographics
NPI:1902158322
Name:MENDOZA, ANGELICA
Entity Type:Individual
Prefix:
First Name:ANGELICA
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 1:3391 RICHMOND AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10312-2025
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4 RAILROAD AVE
Practice Address - Street 2:
Practice Address - City:SOMERSET
Practice Address - State:NJ
Practice Address - Zip Code:08873-2724
Practice Address - Country:US
Practice Address - Phone:732-649-3439
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-09
Last Update Date:2013-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJNJ41YS00748000235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist