Healthcare Provider Details

I. General information

NPI: 1871200493
Provider Name (Legal Business Name): DINA J MENENDEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/02/2022
Last Update Date: 11/11/2022
Certification Date: 11/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

867 N FAIR OAKS AVE
PASADENA CA
91103
US

IV. Provider business mailing address

867 N FAIR OAKS AVE
PASADENA CA
91103
US

V. Phone/Fax

Practice location:
  • Phone: 626-298-3447
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number111729
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: