=====================================================
General NPI Number Information
=====================================================
NPI Number | 1982451803
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LAURI A MENDES MS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/30/2024
-----------------------------------------------------
Last Update Date | 01/09/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 790 S STATE ST STE 6
-----------------------------------------------------
City | SAN JACINTO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92583-4924
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 519-654-6002
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 790 S STATE ST STE 6
-----------------------------------------------------
City | SAN JACINTO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92583-4924
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 951-654-6002
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------