Provider Demographics
NPI:1780889030
Name:MENDONSA, DEBORAH KATHLEEN
Entity type:Individual
Prefix:MS
First Name:DEBORAH
Middle Name:KATHLEEN
Last Name:MENDONSA
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:DEBORAH
Other - Middle Name:KATHLEEN
Other - Last Name:REDMON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 7285
Mailing Address - Street 2:
Mailing Address - City:SOUTH LAKE TAHOE
Mailing Address - State:CA
Mailing Address - Zip Code:96158-0285
Mailing Address - Country:US
Mailing Address - Phone:530-577-8822
Mailing Address - Fax:
Practice Address - Street 1:1137 EMERALD BAY RD
Practice Address - Street 2:
Practice Address - City:SOUTH LAKE TAHOE
Practice Address - State:CA
Practice Address - Zip Code:96150-6207
Practice Address - Country:US
Practice Address - Phone:530-541-5190
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV00995-L101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)