Basic Information
| Provider Information | |||||||||
| NPI: | 1174108732 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MENDOZA | ||||||||
| FirstName: | MIA | ||||||||
| MiddleName: | ANNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 48 CUMMINGS RD APT 2 | ||||||||
| Address2: | |||||||||
| City: | BRIGHTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021357320 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8608336247 | ||||||||
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| Practice Location | |||||||||
| Address1: | 140 HIGH ST STE 203 | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MA | ||||||||
| PostalCode: | 011051435 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4134951500 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/16/2021 | ||||||||
| LastUpdateDate: | 03/16/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/16/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.