Provider Demographics
NPI:1306274071
Name:MENDOZA, SUSY (LMT)
Entity type:Individual
Prefix:MRS
First Name:SUSY
Middle Name:
Last Name:MENDOZA
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:SUSY
Other - Middle Name:
Other - Last Name:MENDOZA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:30 DARTMOUTH ST
Mailing Address - Street 2:
Mailing Address - City:VALLEY STREAM
Mailing Address - State:NY
Mailing Address - Zip Code:11581-3214
Mailing Address - Country:US
Mailing Address - Phone:718-757-6384
Mailing Address - Fax:
Practice Address - Street 1:202 W PARK AVE
Practice Address - Street 2:SUITE 201
Practice Address - City:LONG BEACH
Practice Address - State:NY
Practice Address - Zip Code:11561-3212
Practice Address - Country:US
Practice Address - Phone:718-757-6384
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-16
Last Update Date:2013-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY024660-1225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist