Provider Demographics
NPI:1013240589
Name:MENDES, MARK (OT)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:MENDES
Suffix:
Gender:M
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1301 E BIDWELL ST
Mailing Address - Street 2:SUITE 201
Mailing Address - City:FOLSOM
Mailing Address - State:CA
Mailing Address - Zip Code:95630-3565
Mailing Address - Country:US
Mailing Address - Phone:916-983-5915
Mailing Address - Fax:916-983-5925
Practice Address - Street 1:1100 W MORTON AVE
Practice Address - Street 2:
Practice Address - City:PORTERVILLE
Practice Address - State:CA
Practice Address - Zip Code:93257-1947
Practice Address - Country:US
Practice Address - Phone:559-782-1509
Practice Address - Fax:559-781-5220
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-15
Last Update Date:2009-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA4478225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist