Provider Demographics
NPI:1689493751
Name:MACIAS-MENDOZA, EILEEN MINERVA (MA, BCBA, LBA)
Entity type:Individual
Prefix:
First Name:EILEEN
Middle Name:MINERVA
Last Name:MACIAS-MENDOZA
Suffix:
Gender:F
Credentials:MA, BCBA, LBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3147 JAZZ ST
Mailing Address - Street 2:
Mailing Address - City:ROUND ROCK
Mailing Address - State:TX
Mailing Address - Zip Code:78664-7218
Mailing Address - Country:US
Mailing Address - Phone:714-984-7645
Mailing Address - Fax:
Practice Address - Street 1:104 NORTHWEST DR
Practice Address - Street 2:
Practice Address - City:ROUND ROCK
Practice Address - State:TX
Practice Address - Zip Code:78664-4250
Practice Address - Country:US
Practice Address - Phone:714-984-7645
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-07
Last Update Date:2024-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX7418103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst