Provider Demographics
NPI:1396736294
Name:MORTELLARO, DAWN ZULEME (PT)
Entity type:Individual
Prefix:MRS
First Name:DAWN
Middle Name:ZULEME
Last Name:MORTELLARO
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:DAWN
Other - Middle Name:ZULEME
Other - Last Name:DOERZBACHER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:12415 N 103RD AVE
Mailing Address - Street 2:
Mailing Address - City:SUN CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:85351
Mailing Address - Country:US
Mailing Address - Phone:623-933-6238
Mailing Address - Fax:623-556-2022
Practice Address - Street 1:12415 N 103RD AVE
Practice Address - Street 2:
Practice Address - City:SUN CITY
Practice Address - State:AZ
Practice Address - Zip Code:85351
Practice Address - Country:US
Practice Address - Phone:623-933-6238
Practice Address - Fax:623-556-2022
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-31
Last Update Date:2007-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ648225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ106772Medicare PIN