Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 103TA0400X | Addiction Psychologist (Substance Use Disorder) | 0169701 | NM |
NPI | 1326420951 |
---|---|
Provider Name | Juan Mendoza |
First Address | Las Cruces, NM 88012 |
Second Address | Las Cruces, NM 88007 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 19/06/2015 |
Last Update Date | 19/06/2015 |