Provider Demographics
NPI:1184855652
Name:MENDOZA, DESIREE (PT)
Entity Type:Individual
Prefix:MRS
First Name:DESIREE
Middle Name:
Last Name:MENDOZA
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:591 SUMMIT AVE STE 415
Mailing Address - Street 2:
Mailing Address - City:JERSEY CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:07306-2703
Mailing Address - Country:US
Mailing Address - Phone:201-916-0500
Mailing Address - Fax:
Practice Address - Street 1:591 SUMMIT AVE STE 415
Practice Address - Street 2:
Practice Address - City:JERSEY CITY
Practice Address - State:NJ
Practice Address - Zip Code:07306-2703
Practice Address - Country:US
Practice Address - Phone:201-916-0500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-08-01
Last Update Date:2015-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY027182225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ40QA01578300OtherNJ LICENSE