Provider Demographics
NPI:1053031492
Name:MENDOLA, MORGAN DOREEN
Entity type:Individual
Prefix:
First Name:MORGAN
Middle Name:DOREEN
Last Name:MENDOLA
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 1:1900 OSWEGO DR
Mailing Address - Street 2:
Mailing Address - City:HOLIDAY
Mailing Address - State:FL
Mailing Address - Zip Code:34691-7858
Mailing Address - Country:US
Mailing Address - Phone:727-255-1626
Mailing Address - Fax:
Practice Address - Street 1:6533 RIVER RD
Practice Address - Street 2:
Practice Address - City:NEW PORT RICHEY
Practice Address - State:FL
Practice Address - Zip Code:34652-2229
Practice Address - Country:US
Practice Address - Phone:727-534-3234
Practice Address - Fax:727-255-5151
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-29
Last Update Date:2022-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-22-231780106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1053031492Medicaid