Provider Demographics
NPI:1487107884
Name:MELGOZA, MAIRAH A (PT)
Entity type:Individual
Prefix:
First Name:MAIRAH
Middle Name:A
Last Name:MELGOZA
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1217 W. HOUSTON AVE
Mailing Address - Street 2:
Mailing Address - City:MCALLEN
Mailing Address - State:TX
Mailing Address - Zip Code:78501-5012
Mailing Address - Country:US
Mailing Address - Phone:956-631-9171
Mailing Address - Fax:956-631-9171
Practice Address - Street 1:1217 W. HOUSTON AVE
Practice Address - Street 2:
Practice Address - City:MCALLEN
Practice Address - State:TX
Practice Address - Zip Code:78501-5012
Practice Address - Country:US
Practice Address - Phone:956-631-9171
Practice Address - Fax:956-631-7566
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-02
Last Update Date:2023-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1264830225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX3617565-01Medicaid