Basic Information
| Provider Information | |||||||||
| NPI: | 1568648897 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MENDOZA | ||||||||
| FirstName: | TRICIA | ||||||||
| MiddleName: | POBLETE | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 20 LADD STREET | ||||||||
| Address2: | SUITE 404 | ||||||||
| City: | PORTSMOUTH | ||||||||
| State: | NH | ||||||||
| PostalCode: | 03801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6032052953 | ||||||||
| FaxNumber: | 6034336341 | ||||||||
| Practice Location | |||||||||
| Address1: | 333 BORTHWICK AVE STE 100 | ||||||||
| Address2: | |||||||||
| City: | PORTSMOUTH | ||||||||
| State: | NH | ||||||||
| PostalCode: | 038014198 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6034365110 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/16/2008 | ||||||||
| LastUpdateDate: | 11/18/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 11/18/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | 246874 | NY | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 2084P0805X | 14388 | NH | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Geriatric Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 3098096 | 05 | NH | MEDICAID | 14388 | 01 | NH | NH LICENSE | OTHER | 03061869 | 05 | NY | MEDICAID |