=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902158322
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ANGELICA MENDOZA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/09/2012
-----------------------------------------------------
Last Update Date | 12/18/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4 RAILROAD AVE
-----------------------------------------------------
City | SOMERSET
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08873-2724
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 732-649-3439
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3391 RICHMOND AVE
-----------------------------------------------------
City | STATEN ISLAND
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10312-2025
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 235Z00000X
-----------------------------------------------------
Taxonomy Name | Speech-Language Pathologist
-----------------------------------------------------
License Number | NJ41YS00748000
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------