Provider Demographics
NPI:1366161911
Name:MENDONCA, DIVYA (PT)
Entity type:Individual
Prefix:
First Name:DIVYA
Middle Name:
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 1:1347 W CLIFTON AVE
Mailing Address - Street 2:
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92373-5607
Mailing Address - Country:US
Mailing Address - Phone:909-296-2690
Mailing Address - Fax:
Practice Address - Street 1:10459 MOUNTAIN VIEW AVE STE G
Practice Address - Street 2:
Practice Address - City:LOMA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92354-2033
Practice Address - Country:US
Practice Address - Phone:909-478-9508
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-25
Last Update Date:2022-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA302767225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist