Basic Information
| Provider Information | |||||||||
| NPI: | 1730380841 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MENDIOLA | ||||||||
| FirstName: | DANIEL | ||||||||
| MiddleName: | CRUZ | ||||||||
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| Credential: | OTRL, CHT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 615 LILLY RD NE STE 240 | ||||||||
| Address2: | |||||||||
| City: | OLYMPIA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 985065117 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3604133850 | ||||||||
| FaxNumber: | 3603594726 | ||||||||
| Practice Location | |||||||||
| Address1: | 615 LILLY RD NE STE 240 | ||||||||
| Address2: | |||||||||
| City: | OLYMPIA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 985065117 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3604133850 | ||||||||
| FaxNumber: | 3603594726 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/29/2007 | ||||||||
| LastUpdateDate: | 03/22/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/22/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225XH1200X | OT00000867 | WA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | Hand | 174400000X | OT00000867 | WA | N | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 8341299 | 05 | WA | MEDICAID |