Provider Demographics
NPI:1174108732
Name:MENDOZA, MIA ANNA
Entity type:Individual
Prefix:
First Name:MIA
Middle Name:ANNA
Last Name:MENDOZA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:48 CUMMINGS RD APT 2
Mailing Address - Street 2:
Mailing Address - City:BRIGHTON
Mailing Address - State:MA
Mailing Address - Zip Code:02135-7320
Mailing Address - Country:US
Mailing Address - Phone:860-833-6247
Mailing Address - Fax:
Practice Address - Street 1:140 HIGH ST STE 203
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01105-1435
Practice Address - Country:US
Practice Address - Phone:413-495-1500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-16
Last Update Date:2021-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health