Provider Demographics
NPI:1023234499
Name:MENDOZA, REGINA MARIE
Entity type:Individual
Prefix:
First Name:REGINA
Middle Name:MARIE
Last Name:MENDOZA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1255 38TH AVE SPC 6
Mailing Address - Street 2:
Mailing Address - City:SANTA CRUZ
Mailing Address - State:CA
Mailing Address - Zip Code:95062-3250
Mailing Address - Country:US
Mailing Address - Phone:831-464-3401
Mailing Address - Fax:
Practice Address - Street 1:303 POTRERO ST STE 42-103
Practice Address - Street 2:
Practice Address - City:SANTA CRUZ
Practice Address - State:CA
Practice Address - Zip Code:95060-2779
Practice Address - Country:US
Practice Address - Phone:831-420-0120
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-17
Last Update Date:2008-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA44AVOtherMEDI-CAL PRV NBR