Provider Demographics
NPI:1619261971
Name:MENDOZA, MARIO (OTR/L)
Entity Type:Individual
Prefix:MR
First Name:MARIO
Middle Name:
Last Name:MENDOZA
Suffix:
Gender:M
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 1:26 SEA GATE AVE
Mailing Address - Street 2:
Mailing Address - City:WESTHAMPTON
Mailing Address - State:NY
Mailing Address - Zip Code:11977-1121
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:26 SEA GATE AVE
Practice Address - Street 2:
Practice Address - City:WESTHAMPTON
Practice Address - State:NY
Practice Address - Zip Code:11977-1121
Practice Address - Country:US
Practice Address - Phone:631-998-3046
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-04
Last Update Date:2011-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY010715225X00000X, 225XP0019X, 225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No225XP0019XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPhysical Rehabilitation
No225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics