Provider Demographics
NPI:1144930728
Name:MENDOZA, ODYSSEY FAITH
Entity type:Individual
Prefix:
First Name:ODYSSEY
Middle Name:FAITH
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 1:1107 E SPRUCE ST
Mailing Address - Street 2:
Mailing Address - City:OTHELLO
Mailing Address - State:WA
Mailing Address - Zip Code:99344-1568
Mailing Address - Country:US
Mailing Address - Phone:509-331-4017
Mailing Address - Fax:
Practice Address - Street 1:1107 E SPRUCE ST
Practice Address - Street 2:
Practice Address - City:OTHELLO
Practice Address - State:WA
Practice Address - Zip Code:99344-1568
Practice Address - Country:US
Practice Address - Phone:509-331-4017
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-05
Last Update Date:2022-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician