Provider Demographics
NPI:1376613646
Name:MENDOZA, MARIA THERESA FERNANDEZ (PT)
Entity Type:Individual
Prefix:
First Name:MARIA THERESA
Middle Name:FERNANDEZ
Last Name:MENDOZA
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:MARIA
Other - Middle Name:THERESA
Other - Last Name:CRUZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:801 N I ST APT 104
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98403-2030
Mailing Address - Country:US
Mailing Address - Phone:678-557-0412
Mailing Address - Fax:770-497-6405
Practice Address - Street 1:801 N I ST APT 104
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98403-2030
Practice Address - Country:US
Practice Address - Phone:678-557-0412
Practice Address - Fax:770-497-6405
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-08
Last Update Date:2022-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT007776225100000X
WAPT60886313225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA217472348CMedicaid
GA217472348DMedicaid
GA217472348BMedicaid