Healthcare Provider Details

I. General information

NPI: 1811754161
Provider Name (Legal Business Name): GUILLERMO MARTINEZ MENDOZA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/04/2024
Last Update Date: 02/17/2025
Certification Date: 02/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1851 NW CIVIC DR
GRESHAM OR
97030-5566
US

IV. Provider business mailing address

1333 S MAYFLOWER AVE STE 220
MONROVIA CA
91016-5239
US

V. Phone/Fax

Practice location:
  • Phone: 971-292-1050
  • Fax:
Mailing address:
  • Phone: 818-241-6780
  • Fax: 888-588-2752

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: