Healthcare Provider Details

I. General information

NPI: 1780141820
Provider Name (Legal Business Name): RICHARD MENDOZA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/25/2019
Last Update Date: 09/03/2024
Certification Date: 11/09/2020
Deactivation Date: 07/24/2024
Reactivation Date: 09/03/2024

III. Provider practice location address

3187 AIRWAY AVE STE A
COSTA MESA CA
92626-4603
US

IV. Provider business mailing address

415 NEPONSET AVE STE 3
DORCHESTER MA
02122-3169
US

V. Phone/Fax

Practice location:
  • Phone: 714-881-0427
  • Fax: 714-327-0673
Mailing address:
  • Phone: 857-217-3700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: