Provider Demographics
NPI:1497232979
Name:MENDIOLA, MARIA FIDELA (OTR/L)
Entity Type:Individual
Prefix:
First Name:MARIA
Middle Name:FIDELA
Last Name:MENDIOLA
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:118 HERRON ST
Mailing Address - Street 2:
Mailing Address - City:FORT OGLETHORPE
Mailing Address - State:GA
Mailing Address - Zip Code:30742-3126
Mailing Address - Country:US
Mailing Address - Phone:706-861-7471
Mailing Address - Fax:
Practice Address - Street 1:118 HERRON ST
Practice Address - Street 2:
Practice Address - City:FORT OGLETHORPE
Practice Address - State:GA
Practice Address - Zip Code:30742-3126
Practice Address - Country:US
Practice Address - Phone:706-861-7471
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-26
Last Update Date:2018-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOT007073225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAOT007073OtherOT LICENSE