Healthcare Provider Details

I. General information

NPI: 1750993044
Provider Name (Legal Business Name): EVELYN EDITH MENDEZ BS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/19/2020
Last Update Date: 06/24/2021
Certification Date: 06/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 W LA JOLLA DR APT 1018
TEMPE AZ
85282-4433
US

IV. Provider business mailing address

1600 W LA JOLLA DR APT 1018
TEMPE AZ
85282-4433
US

V. Phone/Fax

Practice location:
  • Phone: 928-323-7407
  • Fax:
Mailing address:
  • Phone: 928-323-7407
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2355S0801X
TaxonomySpeech-Language Assistant
License NumberSLPA13134
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-20-131451
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: