1356558688 NPI number — MR. JAIME MENDEZ LICSW

Table of content: MR. JAIME MENDEZ LICSW (NPI 1356558688)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356558688 NPI number — MR. JAIME MENDEZ LICSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MENDEZ
Provider First Name:
JAIME
Provider Middle Name:
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
LICSW
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1356558688
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/31/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
24 ANNETTE AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PAWTUCKET
Provider Business Mailing Address State Name:
RI
Provider Business Mailing Address Postal Code:
02861-4418
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
401-640-3917
Provider Business Mailing Address Fax Number:
401-525-2557

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
830 CHALKSTONE AVE
Provider Second Line Business Practice Location Address:
TRAILER 36
Provider Business Practice Location Address City Name:
PROVIDENCE
Provider Business Practice Location Address State Name:
RI
Provider Business Practice Location Address Postal Code:
02908-4734
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
401-640-3917
Provider Business Practice Location Address Fax Number:
401-525-2557
Provider Enumeration Date:
05/17/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  ISW02030 , registered in the state of RI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: JM66771 , issued by the state of ( RI ) . This identifiers is of the category "MEDICAID".




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