Provider Demographics
NPI:1083051452
Name:IMPERIAL, MARY GRACE MENDOZA (OTR)
Entity Type:Individual
Prefix:
First Name:MARY GRACE
Middle Name:MENDOZA
Last Name:IMPERIAL
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4234 79TH ST
Mailing Address - Street 2:
Mailing Address - City:ELMHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11373-3057
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2865 BRIGHTON 3RD ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11235-6762
Practice Address - Country:US
Practice Address - Phone:718-891-4400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-25
Last Update Date:2013-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY017762-1225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist