Provider Demographics
NPI:1366742702
Name:MENDEZ, NICOLE MICHELLE
Entity type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:MICHELLE
Last Name:MENDEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:NICOLE
Other - Middle Name:MICHELLE
Other - Last Name:GARCIA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1320 S. SOLANO
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88001
Mailing Address - Country:US
Mailing Address - Phone:575-527-7900
Mailing Address - Fax:575-571-4872
Practice Address - Street 1:249 WHITE MOUNTAIN DR.
Practice Address - Street 2:
Practice Address - City:MESCALERO
Practice Address - State:NM
Practice Address - Zip Code:88340
Practice Address - Country:US
Practice Address - Phone:575-464-0016
Practice Address - Fax:575-464-0010
Is Sole Proprietor?:No
Enumeration Date:2010-11-02
Last Update Date:2014-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM18677037Medicaid