MEDICARE: MRS. IDALIA G MENDOZA LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	23619	TX
2	104100000X	Social Worker	S23619	TX

General Provider Information

NPI Number	:	1073625091
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. IDALIA G MENDOZA LCSW

Provider Business Mailing Address
First Line	:	202 REBECCA DR
Second Line	:
City	:	EDINBURG
State	:	TX
Zip	:	78542-0635
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4528 E INGLE RD
Second Line	:
City	:	EDINBURG
State	:	TX
Zip	:	78541
Country	:	US
Telephone Number	:	956-618-7107
Fax Number	:	956-618-7148

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/31/2006
Last Update Date	:	08/02/2018

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