Provider Demographics
NPI:1659024479
Name:MENDOZA SANTIAGO, ALFREDO AMADOR (QMHA, CADC-R, CRM)
Entity type:Individual
Prefix:
First Name:ALFREDO
Middle Name:AMADOR
Last Name:MENDOZA SANTIAGO
Suffix:
Gender:M
Credentials:QMHA, CADC-R, CRM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1050 PRICE RD SE
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:OR
Mailing Address - Zip Code:97322-7314
Mailing Address - Country:US
Mailing Address - Phone:541-928-9681
Mailing Address - Fax:
Practice Address - Street 1:1050 PRICE RD SE
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:OR
Practice Address - Zip Code:97322-7314
Practice Address - Country:US
Practice Address - Phone:541-928-9681
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-01
Last Update Date:2024-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR23-QMHA-I-004017101YM0800X
OR22-CRM-824172V00000X
ORT-22-1786101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No172V00000XOther Service ProvidersCommunity Health Worker