Healthcare Provider Details

I. General information

NPI: 1760547053
Provider Name (Legal Business Name): SUSANA ELENA MENDEZ L.AC, LCDC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/27/2006
Last Update Date: 05/18/2023
Certification Date: 05/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14114 DALLAS PKWY STE 245
DALLAS TX
75254-1331
US

IV. Provider business mailing address

50 PATRICK CT
VAN ALSTYNE TX
75495-3456
US

V. Phone/Fax

Practice location:
  • Phone: 214-566-0149
  • Fax:
Mailing address:
  • Phone: 214-566-0149
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number5991
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberAC00939
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: