Healthcare Provider Details

I. General information

NPI: 1619627551
Provider Name (Legal Business Name): LISA D MENDOZA LPCC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/24/2022
Last Update Date: 08/06/2025
Certification Date: 08/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2626 E 82ND ST STE 335
BLOOMINGTON MN
55425-1682
US

IV. Provider business mailing address

3335 BUCHANAN ST NE
MINNEAPOLIS MN
55418-1449
US

V. Phone/Fax

Practice location:
  • Phone: 651-263-4149
  • Fax:
Mailing address:
  • Phone: 651-263-4149
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberCC04077
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number
License Number StateMN
# 3
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: