Provider Demographics
NPI:1538366927
Name:MANN, MAE T (PT)
Entity type:Individual
Prefix:
First Name:MAE
Middle Name:T
Last Name:MANN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6297 CANAK DR
Mailing Address - Street 2:
Mailing Address - City:AVON
Mailing Address - State:IN
Mailing Address - Zip Code:46123-7435
Mailing Address - Country:US
Mailing Address - Phone:173-250-9219
Mailing Address - Fax:
Practice Address - Street 1:6297 CANAK DR
Practice Address - Street 2:
Practice Address - City:AVON
Practice Address - State:IN
Practice Address - Zip Code:46123-7435
Practice Address - Country:US
Practice Address - Phone:317-250-9219
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-28
Last Update Date:2024-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05005457A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100266570AMedicaid