Provider Demographics
NPI:1730556820
Name:MENDOZA, JOHN
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:MENDOZA
Suffix:
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 1:333 SUNRISE AVE STE 701
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95661-3483
Mailing Address - Country:US
Mailing Address - Phone:916-783-5207
Mailing Address - Fax:
Practice Address - Street 1:2178 JOHNSON AVE
Practice Address - Street 2:
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401-4535
Practice Address - Country:US
Practice Address - Phone:805-781-1553
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-25
Last Update Date:2015-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT 26657103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst