Provider Demographics
NPI:1215364369
Name:MAYORGA, LUCY (PTA)
Entity Type:Individual
Prefix:
First Name:LUCY
Middle Name:
Last Name:MAYORGA
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:311 NE 8TH ST STE 104
Mailing Address - Street 2:
Mailing Address - City:HOMESTEAD
Mailing Address - State:FL
Mailing Address - Zip Code:33030-4734
Mailing Address - Country:US
Mailing Address - Phone:305-245-0356
Mailing Address - Fax:
Practice Address - Street 1:311 NE 8TH ST STE 104
Practice Address - Street 2:
Practice Address - City:HOMESTEAD
Practice Address - State:FL
Practice Address - Zip Code:33030-4734
Practice Address - Country:US
Practice Address - Phone:305-245-0356
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-03
Last Update Date:2013-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL21865225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL21865OtherPTA FL LICENSE