Provider Demographics
NPI:1528254349
Name:MANCHANDA, MAMTA (LPT)
Entity type:Individual
Prefix:
First Name:MAMTA
Middle Name:
Last Name:MANCHANDA
Suffix:
Gender:F
Credentials:LPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15617 SOMERGLEN CT
Mailing Address - Street 2:
Mailing Address - City:ORLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60467-4585
Mailing Address - Country:US
Mailing Address - Phone:708-878-8342
Mailing Address - Fax:708-226-4817
Practice Address - Street 1:10723 WINTERSET DR
Practice Address - Street 2:
Practice Address - City:ORLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60467-1106
Practice Address - Country:US
Practice Address - Phone:708-364-7087
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-16
Last Update Date:2007-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILL74110Medicare PIN