Provider Demographics
NPI:1588003453
Name:MENDEZ, THERESA ELIZABETH
Entity Type:Individual
Prefix:MISS
First Name:THERESA
Middle Name:ELIZABETH
Last Name:MENDEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7609 79TH ST
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:NY
Mailing Address - Zip Code:11385-7540
Mailing Address - Country:US
Mailing Address - Phone:718-456-5014
Mailing Address - Fax:
Practice Address - Street 1:7609 79TH ST
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:NY
Practice Address - Zip Code:11385-7540
Practice Address - Country:US
Practice Address - Phone:718-456-5014
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-24
Last Update Date:2013-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1276356174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist