=====================================================
General NPI Number Information
=====================================================
NPI Number | 1326573338
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SUSAN K. MENDEZ, PSY.D.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/27/2017
-----------------------------------------------------
Last Update Date | 04/27/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1453 45TH ST
-----------------------------------------------------
City | SACRAMENTO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95819-4137
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 916-761-7768
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1453 45TH ST
-----------------------------------------------------
City | SACRAMENTO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95819-4137
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CLINICAL PSYCHOLOGIST
-----------------------------------------------------
Name | DR. SUSAN KATHRYN MENDEZ
-----------------------------------------------------
Credential | PSY.D.
-----------------------------------------------------
Telephone | 916-761-7768
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number | PSY#28871
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------