Provider Demographics
NPI:1699060947
Name:MANALP, MARK SHAHAN (PTA)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:SHAHAN
Last Name:MANALP
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:217 W ALLEN ST
Mailing Address - Street 2:BOX 304
Mailing Address - City:HANOVER
Mailing Address - State:MI
Mailing Address - Zip Code:49241-8605
Mailing Address - Country:US
Mailing Address - Phone:734-218-6404
Mailing Address - Fax:
Practice Address - Street 1:434 W NORTH ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49202-3313
Practice Address - Country:US
Practice Address - Phone:517-787-3250
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-15
Last Update Date:2011-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5502002778225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant