Provider Demographics
NPI:1407521727
Name:MENDOZA, MARIE BERNADETTE (PT, DPT)
Entity Type:Individual
Prefix:
First Name:MARIE BERNADETTE
Middle Name:
Last Name:MENDOZA
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:MARIE BERNADETTE
Other - Middle Name:
Other - Last Name:SALGADO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:600 E FICKLIN ST APT 316
Mailing Address - Street 2:
Mailing Address - City:TUSCOLA
Mailing Address - State:IL
Mailing Address - Zip Code:61953-1918
Mailing Address - Country:US
Mailing Address - Phone:360-470-4546
Mailing Address - Fax:
Practice Address - Street 1:600 E FICKLIN ST APT 316
Practice Address - Street 2:
Practice Address - City:TUSCOLA
Practice Address - State:IL
Practice Address - Zip Code:61953-1918
Practice Address - Country:US
Practice Address - Phone:360-470-4546
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-10
Last Update Date:2021-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070025025208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation