Provider Demographics
NPI:1104808955
Name:MENDELSON, BRUCE (MSPT)
Entity type:Individual
Prefix:
First Name:BRUCE
Middle Name:
Last Name:MENDELSON
Suffix:
Gender:M
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11481 SW HALL BV
Mailing Address - Street 2:THERAPEUTIC ASSOCIATES INC STE 201
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97223-8403
Mailing Address - Country:US
Mailing Address - Phone:800-219-8835
Mailing Address - Fax:503-443-1402
Practice Address - Street 1:849 NE 7TH STREET
Practice Address - Street 2:TAI GRANTS PASS
Practice Address - City:GRANTS PASS
Practice Address - State:OR
Practice Address - Zip Code:97526-1634
Practice Address - Country:US
Practice Address - Phone:541-479-0765
Practice Address - Fax:541-479-3461
Is Sole Proprietor?:No
Enumeration Date:2005-11-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR4573225100000X
AR2220225100000X
225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR297999Medicaid
131235Medicare ID - Type Unspecified
OR297999Medicaid