Provider Demographics
NPI:1356491781
Name:MERCADO, LEA ANTONIO (PT)
Entity Type:Individual
Prefix:MRS
First Name:LEA
Middle Name:ANTONIO
Last Name:MERCADO
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:LEA
Other - Middle Name:D
Other - Last Name:ANTONIO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:6635 S STAPLES ST APT 918
Mailing Address - Street 2:
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78413-5411
Mailing Address - Country:US
Mailing Address - Phone:361-980-1967
Mailing Address - Fax:
Practice Address - Street 1:600 ELIZABETH ST
Practice Address - Street 2:
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78404-2235
Practice Address - Country:US
Practice Address - Phone:361-881-3802
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-10
Last Update Date:2014-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1118560225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist