Provider Demographics
NPI:1629573522
Name:MENDOLA, ELIZABETH (MS, ATC, LAT)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:MENDOLA
Suffix:
Gender:F
Credentials:MS, ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:701 LEORA LN APT 837
Mailing Address - Street 2:
Mailing Address - City:LEWISVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75056-3950
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3201 OLD DENTON RD
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:TX
Practice Address - Zip Code:75007-3957
Practice Address - Country:US
Practice Address - Phone:972-968-4900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-24
Last Update Date:2018-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAT56392081S0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
2000013779OtherBOC CERTIFIED ATHLETIC TRAINER
59927OtherNATIONAL ATHLETIC TRAINERS ASSOCIATION MEMBER