Provider Demographics
NPI:1508815432
Name:MENDENHALL, MARSHA (OT)
Entity Type:Individual
Prefix:
First Name:MARSHA
Middle Name:
Last Name:MENDENHALL
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 1:1031 E MOUNTAIN ST
Mailing Address - Street 2:BUILDING 318. SUITE 101
Mailing Address - City:KERNERSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27284-7997
Mailing Address - Country:US
Mailing Address - Phone:336-996-4980
Mailing Address - Fax:336-996-3521
Practice Address - Street 1:1031 E MOUNTAIN ST
Practice Address - Street 2:BUILDING 318. SUITE 101
Practice Address - City:KERNERSVILLE
Practice Address - State:NC
Practice Address - Zip Code:27284-7997
Practice Address - Country:US
Practice Address - Phone:336-996-4980
Practice Address - Fax:336-996-3521
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5098225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7301804Medicaid