Provider Demographics
NPI:1386995959
Name:HENDRICKS-MANTECA, DONNA MARIE (DT)
Entity type:Individual
Prefix:MS
First Name:DONNA
Middle Name:MARIE
Last Name:HENDRICKS-MANTECA
Suffix:
Gender:F
Credentials:DT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5633 CRESTWOOD RD
Mailing Address - Street 2:
Mailing Address - City:MATTESON
Mailing Address - State:IL
Mailing Address - Zip Code:60443-1119
Mailing Address - Country:US
Mailing Address - Phone:708-862-4323
Mailing Address - Fax:708-720-2740
Practice Address - Street 1:5633 CRESTWOOD RD
Practice Address - Street 2:
Practice Address - City:MATTESON
Practice Address - State:IL
Practice Address - Zip Code:60443-1119
Practice Address - Country:US
Practice Address - Phone:708-862-4323
Practice Address - Fax:708-720-2740
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-24
Last Update Date:2012-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist