Provider Demographics
NPI:1750945572
Name:DIZON, MYLENE SANTOS
Entity type:Individual
Prefix:
First Name:MYLENE
Middle Name:SANTOS
Last Name:DIZON
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 1:5007 BLANCO DR
Mailing Address - Street 2:
Mailing Address - City:PEARLAND
Mailing Address - State:TX
Mailing Address - Zip Code:77584-1433
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4048 RED BLUFF RD
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:TX
Practice Address - Zip Code:77503-3606
Practice Address - Country:US
Practice Address - Phone:832-618-5650
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-26
Last Update Date:2019-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX111191225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist