Provider Demographics
NPI:1396179966
Name:MHANNA, THERESA (DAOM, OM, LAC)
Entity type:Individual
Prefix:DR
First Name:THERESA
Middle Name:
Last Name:MHANNA
Suffix:
Gender:F
Credentials:DAOM, OM, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3907 GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:OH
Mailing Address - Zip Code:45044-6123
Mailing Address - Country:US
Mailing Address - Phone:513-329-5793
Mailing Address - Fax:
Practice Address - Street 1:3907 GRAND AVE
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:OH
Practice Address - Zip Code:45044-6123
Practice Address - Country:US
Practice Address - Phone:513-329-5793
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-30
Last Update Date:2022-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH65.000239171100000X
171100000X
OH66.000032171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH460585977-00OtherBWC
OH1396179966Medicaid