Provider Demographics
NPI:1922822311
Name:MENDES, MARINA (APCC15511)
Entity type:Individual
Prefix:
First Name:MARINA
Middle Name:
Last Name:MENDES
Suffix:
Gender:F
Credentials:APCC15511
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1977 N KENMORE AVE APT 3
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90027-1895
Mailing Address - Country:US
Mailing Address - Phone:847-826-8396
Mailing Address - Fax:
Practice Address - Street 1:5619 N FIGUEROA ST
Practice Address - Street 2:
Practice Address - City:HIGHLAND PARK
Practice Address - State:CA
Practice Address - Zip Code:90042-4977
Practice Address - Country:US
Practice Address - Phone:213-302-5216
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-12
Last Update Date:2024-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA15511101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health