=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205659505
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KARINA MENDOZA MA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/05/2024
-----------------------------------------------------
Last Update Date | 11/05/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 17203 VENTURA BLVD STE 3
-----------------------------------------------------
City | ENCINO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91316-4055
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-501-3615
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 17203 VENTURA BLVD STE 3
-----------------------------------------------------
City | ENCINO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91316-4055
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-501-3615
-----------------------------------------------------
Fax | 818-501-3649
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103K00000X
-----------------------------------------------------
Taxonomy Name | Behavior Analyst
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------