Provider Demographics
NPI:1114439866
Name:MENDEZ, MICHELLE LORA
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:LORA
Last Name:MENDEZ
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 1:4360 DINNER LAKE BLVD
Mailing Address - Street 2:
Mailing Address - City:LAKE WALES
Mailing Address - State:FL
Mailing Address - Zip Code:33859-2129
Mailing Address - Country:US
Mailing Address - Phone:863-232-7615
Mailing Address - Fax:
Practice Address - Street 1:4360 DINNER LAKE BLVD
Practice Address - Street 2:
Practice Address - City:LAKE WALES
Practice Address - State:FL
Practice Address - Zip Code:33859-2129
Practice Address - Country:US
Practice Address - Phone:863-232-7615
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-02
Last Update Date:2021-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL222Q00000X, 222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist