Provider Demographics
NPI:1417309196
Name:BRENILDA MENDOZA
Entity Type:Organization
Organization Name:BRENILDA MENDOZA
Other - Org Name:BRENILDA MENDOZA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:LICENSE
Authorized Official - Prefix:
Authorized Official - First Name:BRENILDA
Authorized Official - Middle Name:LUZ
Authorized Official - Last Name:MENDOZA
Authorized Official - Suffix:
Authorized Official - Credentials:COTA
Authorized Official - Phone:407-747-4288
Mailing Address - Street 1:628 GAZELLE DR
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34759-4208
Mailing Address - Country:US
Mailing Address - Phone:407-747-4288
Mailing Address - Fax:
Practice Address - Street 1:628 GAZELLE DR
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34759-4208
Practice Address - Country:US
Practice Address - Phone:407-747-4288
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-06
Last Update Date:2016-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOTA13972224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy AssistantGroup - Single Specialty