Provider Demographics
NPI:1790187631
Name:MONDELLO, FREEBORN
Entity Type:Individual
Prefix:
First Name:FREEBORN
Middle Name:
Last Name:MONDELLO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 MEADOW HAWK LN
Mailing Address - Street 2:
Mailing Address - City:SILVER CITY
Mailing Address - State:NM
Mailing Address - Zip Code:88022-9727
Mailing Address - Country:US
Mailing Address - Phone:541-951-8170
Mailing Address - Fax:
Practice Address - Street 1:20 MEADOW HAWK LN
Practice Address - Street 2:
Practice Address - City:SILVER CITY
Practice Address - State:NM
Practice Address - Zip Code:88022-9727
Practice Address - Country:US
Practice Address - Phone:541-951-8170
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-23
Last Update Date:2014-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO12654225100000X
NM4487225100000X
MA21351225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist