Provider Demographics
NPI:1578978680
Name:MENDOZA, MADISON (BCBA)
Entity type:Individual
Prefix:MRS
First Name:MADISON
Middle Name:
Last Name:MENDOZA
Suffix:
Gender:
Credentials:BCBA
Other - Prefix:
Other - First Name:MADISON
Other - Middle Name:
Other - Last Name:UMPHRES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BCBA
Mailing Address - Street 1:4842 JOHNSON POINT RD NE
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98516-9152
Mailing Address - Country:US
Mailing Address - Phone:360-515-8620
Mailing Address - Fax:
Practice Address - Street 1:4842 JOHNSON POINT RD NE
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98516-9152
Practice Address - Country:US
Practice Address - Phone:520-429-5022
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-26
Last Update Date:2025-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WABA60771905103K00000X
WA103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst