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NPI Code Detail

MEDICARE: MRS. TANNIELLE MARIE MENDOZA LCSW

MEDICARE: MRS. TANNIELLE MARIE MENDOZA LCSW
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
11041C0700XClinical Social Worker8693626-3502UT
21041C0700XClinical Social Worker8693626-3501UT

General Provider Information

NPI Number : 1790186948
Entity Type Code : Individual
Provider Name (Legal Business Name) : MRS. TANNIELLE MARIE MENDOZA LCSW
Provider Business Mailing Address
First Line : 62 MANCHESTER DR
Second Line :
City : FAIRFIELD
State : CA
Zip : 94533-6546
Country : US
Telephone Number : 509-386-1850
Fax Number :
Provider Business Practice Location Address
First Line : 2825 E COTTONWOOD PKWY STE 500
Second Line :
City : SALT LAKE CITY
State : UT
Zip : 84121-7060
Country : US
Telephone Number : 929-596-7897
Fax Number : 929-596-7897
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 09/08/2014
Last Update Date : 03/30/2026

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