Healthcare Provider Details

I. General information

NPI: 1174123178
Provider Name (Legal Business Name): KAREN RAQUEL MENDOZA LCSW-S
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/28/2020
Last Update Date: 02/03/2021
Certification Date: 10/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1601 TRINITY ST
AUSTIN TX
78712-1765
US

IV. Provider business mailing address

1601 TRINITY ST
AUSTIN TX
78712-1765
US

V. Phone/Fax

Practice location:
  • Phone: 512-495-5000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number54109
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: