Provider Demographics
NPI:1588155246
Name:MENDOZA, MABELLE CHAN
Entity type:Individual
Prefix:
First Name:MABELLE
Middle Name:CHAN
Last Name:MENDOZA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2345 BIEHN ST
Mailing Address - Street 2:
Mailing Address - City:KLAMATH FALLS
Mailing Address - State:OR
Mailing Address - Zip Code:97601-1761
Mailing Address - Country:US
Mailing Address - Phone:541-882-4612
Mailing Address - Fax:541-273-2908
Practice Address - Street 1:2345 BIEHN ST
Practice Address - Street 2:
Practice Address - City:KLAMATH FALLS
Practice Address - State:OR
Practice Address - Zip Code:97601-1761
Practice Address - Country:US
Practice Address - Phone:541-882-4612
Practice Address - Fax:541-273-2908
Is Sole Proprietor?:No
Enumeration Date:2018-05-29
Last Update Date:2018-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR62768225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR62768OtherSTATE OF OREGON PHYSICAL THERAPIST LICENSING BOARD