Provider Demographics
NPI:1154619716
Name:MANNINO, RAE (OT)
Entity type:Individual
Prefix:
First Name:RAE
Middle Name:
Last Name:MANNINO
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35 RIVER RD
Mailing Address - Street 2:
Mailing Address - City:COS COB
Mailing Address - State:CT
Mailing Address - Zip Code:06807-2759
Mailing Address - Country:US
Mailing Address - Phone:203-422-0679
Mailing Address - Fax:203-422-0931
Practice Address - Street 1:35 RIVER RD
Practice Address - Street 2:
Practice Address - City:COS COB
Practice Address - State:CT
Practice Address - Zip Code:06807-2759
Practice Address - Country:US
Practice Address - Phone:203-422-0679
Practice Address - Fax:203-422-0931
Is Sole Proprietor?:No
Enumeration Date:2011-07-18
Last Update Date:2013-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY015452-1225X00000X
CT3873225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist