Provider Demographics
NPI:1801313523
Name:MCLENDON, MOUHAR (PTA)
Entity type:Individual
Prefix:MRS
First Name:MOUHAR
Middle Name:
Last Name:MCLENDON
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3568 ATHERTON ST
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32207-3861
Mailing Address - Country:US
Mailing Address - Phone:904-887-0633
Mailing Address - Fax:
Practice Address - Street 1:1835 EASTWEST PKWY STE 16
Practice Address - Street 2:
Practice Address - City:FLEMING ISLAND
Practice Address - State:FL
Practice Address - Zip Code:32003-5311
Practice Address - Country:US
Practice Address - Phone:904-215-3958
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-23
Last Update Date:2017-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA27516225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant