Provider Demographics
NPI:1215718572
Name:MENDOZA, MAH-ANN
Entity type:Individual
Prefix:
First Name:MAH-ANN
Middle Name:
Last Name:MENDOZA
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 1:5244 WILLOW LEAF ST N
Mailing Address - Street 2:
Mailing Address - City:KEIZER
Mailing Address - State:OR
Mailing Address - Zip Code:97303-7519
Mailing Address - Country:US
Mailing Address - Phone:503-580-9771
Mailing Address - Fax:503-393-1080
Practice Address - Street 1:2195 HYACINTH ST NE STE 144
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-3116
Practice Address - Country:US
Practice Address - Phone:503-580-9771
Practice Address - Fax:503-393-1080
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-11
Last Update Date:2023-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR6588225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist