Healthcare Provider Details

I. General information

NPI: 1396491460
Provider Name (Legal Business Name): BROOKLYN MENDEZ PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/26/2022
Last Update Date: 02/26/2022
Certification Date: 02/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

221 TRAILWOOD DR
CLINTON MS
39056-5869
US

IV. Provider business mailing address

221 TRAILWOOD DR
CLINTON MS
39056-5869
US

V. Phone/Fax

Practice location:
  • Phone: 985-502-5621
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: