Provider Demographics
NPI:1245686658
Name:MENDOZA, BENJAMIN R JR
Entity type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:R
Last Name:MENDOZA
Suffix:JR
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 1:5429 OVANDO WAY
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89122-8652
Mailing Address - Country:US
Mailing Address - Phone:808-381-2971
Mailing Address - Fax:
Practice Address - Street 1:5429 OVANDO WAY
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89122-8652
Practice Address - Country:US
Practice Address - Phone:808-381-2971
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-05
Last Update Date:2016-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor