Provider Demographics
NPI:1548325814
Name:MANNELLO, MICK (DPT)
Entity type:Individual
Prefix:DR
First Name:MICK
Middle Name:
Last Name:MANNELLO
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:428 CENTRAL PARK AVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:SCARSDALE
Mailing Address - State:NY
Mailing Address - Zip Code:10583-1017
Mailing Address - Country:US
Mailing Address - Phone:914-713-4420
Mailing Address - Fax:914-709-4002
Practice Address - Street 1:428 CENTRAL PARK AVE
Practice Address - Street 2:
Practice Address - City:SCARSDALE
Practice Address - State:NY
Practice Address - Zip Code:10583-1017
Practice Address - Country:US
Practice Address - Phone:914-713-4420
Practice Address - Fax:914-709-4002
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-26
Last Update Date:2016-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY028705225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYQ70311Medicare PIN