Provider Demographics
NPI:1891100145
Name:MONDGOCK, THERESA
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:MONDGOCK
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 1:2280 E CALVADA BLVD STE 301
Mailing Address - Street 2:
Mailing Address - City:PAHRUMP
Mailing Address - State:NV
Mailing Address - Zip Code:89048-5877
Mailing Address - Country:US
Mailing Address - Phone:775-751-5211
Mailing Address - Fax:
Practice Address - Street 1:2280 E CALVADA BLVD STE 301
Practice Address - Street 2:
Practice Address - City:PAHRUMP
Practice Address - State:NV
Practice Address - Zip Code:89048-5877
Practice Address - Country:US
Practice Address - Phone:775-751-5211
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-25
Last Update Date:2014-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner