Basic Information
| Provider Information | |||||||||
| NPI: | 1497232979 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MENDIOLA | ||||||||
| FirstName: | MARIA | ||||||||
| MiddleName: | FIDELA | ||||||||
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| Credential: | OTR/L | ||||||||
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| Mailing Information | |||||||||
| Address1: | 118 HERRON ST | ||||||||
| Address2: | |||||||||
| City: | FORT OGLETHORPE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 307423126 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7068617471 | ||||||||
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| Practice Location | |||||||||
| Address1: | 118 HERRON ST | ||||||||
| Address2: | |||||||||
| City: | FORT OGLETHORPE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 307423126 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7068617471 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/26/2018 | ||||||||
| LastUpdateDate: | 07/26/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | OT007073 | GA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
ID Information
| ID | Type | State | Issuer | Description | OT007073 | 01 | GA | OT LICENSE | OTHER |