Provider Demographics
NPI:1962621086
Name:MANNING, KATHLEEN ANN (PTA)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:ANN
Last Name:MANNING
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:53 MILLER ST
Mailing Address - Street 2:
Mailing Address - City:JOHNSTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:12095-1315
Mailing Address - Country:US
Mailing Address - Phone:518-844-3595
Mailing Address - Fax:
Practice Address - Street 1:681 BEVILLE RD
Practice Address - Street 2:
Practice Address - City:SOUTH DAYTONA
Practice Address - State:FL
Practice Address - Zip Code:32119-1951
Practice Address - Country:US
Practice Address - Phone:386-756-4395
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA20050225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant