Provider Demographics
NPI:1861826166
Name:MENDIOLA, MA LIZZA MARTINEZ (RPT)
Entity Type:Individual
Prefix:
First Name:MA LIZZA
Middle Name:MARTINEZ
Last Name:MENDIOLA
Suffix:
Gender:F
Credentials:RPT
Other - Prefix:
Other - First Name:LIZZA
Other - Middle Name:
Other - Last Name:MENDIOLA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RPT
Mailing Address - Street 1:106 COTTONWOOD DR
Mailing Address - Street 2:
Mailing Address - City:CHATHAM
Mailing Address - State:IL
Mailing Address - Zip Code:62629-1047
Mailing Address - Country:US
Mailing Address - Phone:217-220-1961
Mailing Address - Fax:
Practice Address - Street 1:106 COTTONWOOD DR
Practice Address - Street 2:
Practice Address - City:CHATHAM
Practice Address - State:IL
Practice Address - Zip Code:62629-1047
Practice Address - Country:US
Practice Address - Phone:217-220-1961
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-23
Last Update Date:2013-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070016331225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist