Provider Demographics
NPI:1376842419
Name:DE GUZMAN, MARY ANN MENDOZA (OT)
Entity Type:Individual
Prefix:MRS
First Name:MARY ANN
Middle Name:MENDOZA
Last Name:DE GUZMAN
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2535 WOODHILL WAY
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-2613
Mailing Address - Country:US
Mailing Address - Phone:208-233-1679
Mailing Address - Fax:
Practice Address - Street 1:1200 HOSPITAL WAY
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-2708
Practice Address - Country:US
Practice Address - Phone:208-232-2570
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-15
Last Update Date:2011-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDOT-906225XG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XG0600XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGerontology