Provider Demographics
NPI:1902140510
Name:MASCARENAS, ADELA B (PT, DPT)
Entity Type:Individual
Prefix:
First Name:ADELA
Middle Name:B
Last Name:MASCARENAS
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23760 SE TILLSTROM RD
Mailing Address - Street 2:
Mailing Address - City:DAMASCUS
Mailing Address - State:OR
Mailing Address - Zip Code:97089-6174
Mailing Address - Country:US
Mailing Address - Phone:503-544-2525
Mailing Address - Fax:
Practice Address - Street 1:179 BRIDGE ST
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NM
Practice Address - Zip Code:87701-3495
Practice Address - Country:US
Practice Address - Phone:505-426-2318
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-20
Last Update Date:2012-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM4215225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist