Provider Demographics
NPI:1356808810
Name:MENDOZA, KATHERINE NICOLE (LMT)
Entity type:Individual
Prefix:
First Name:KATHERINE
Middle Name:NICOLE
Last Name:MENDOZA
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8701 KENNEDY BLVD
Mailing Address - Street 2:
Mailing Address - City:NORTH BERGEN
Mailing Address - State:NJ
Mailing Address - Zip Code:07047-4387
Mailing Address - Country:US
Mailing Address - Phone:201-737-4224
Mailing Address - Fax:
Practice Address - Street 1:4713 BERGENLINE AVE APT 2
Practice Address - Street 2:
Practice Address - City:UNION CITY
Practice Address - State:NJ
Practice Address - Zip Code:07087-5195
Practice Address - Country:US
Practice Address - Phone:201-737-4224
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-20
Last Update Date:2020-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ18KT00754600225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist