Provider Demographics
NPI:1871605337
Name:MENDONCA, CARROLL ANN (PT)
Entity type:Individual
Prefix:MRS
First Name:CARROLL
Middle Name:ANN
Last Name:MENDONCA
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 1:12711 111TH AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH OZONE PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11420-1604
Mailing Address - Country:US
Mailing Address - Phone:718-738-2236
Mailing Address - Fax:718-738-2195
Practice Address - Street 1:12711 111TH AVE
Practice Address - Street 2:
Practice Address - City:SOUTH OZONE PARK
Practice Address - State:NY
Practice Address - Zip Code:11420-1604
Practice Address - Country:US
Practice Address - Phone:718-322-7967
Practice Address - Fax:718-738-2236
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY022988225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYXC2685OtherHEALTHNET
NY69520OtherCAREPLUS
NYGQ537OtherBLUE CROSS BLUE SHIELD
NY126019POtherHIP
NY98123701OtherNEIGHBORHOOD HEALTH PROVI
NY022988-A81OtherHEALTHFIRST
NY02285481Medicaid
NYXC2685OtherHEALTHNET
NY05732Medicare ID - Type Unspecified