Provider Demographics
NPI:1144936642
Name:MENDIZABAL, MARK (MDIV, BCC)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:MENDIZABAL
Suffix:
Gender:M
Credentials:MDIV, BCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4417 HUNGARY GLEN TER
Mailing Address - Street 2:
Mailing Address - City:HENRICO
Mailing Address - State:VA
Mailing Address - Zip Code:23294-6048
Mailing Address - Country:US
Mailing Address - Phone:804-508-3078
Mailing Address - Fax:
Practice Address - Street 1:4417 HUNGARY GLEN TER
Practice Address - Street 2:
Practice Address - City:HENRICO
Practice Address - State:VA
Practice Address - Zip Code:23294-6048
Practice Address - Country:US
Practice Address - Phone:804-508-3078
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-27
Last Update Date:2023-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral