Basic Information
| Provider Information | |||||||||
| NPI: | 1417350521 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MANEY | ||||||||
| FirstName: | KATIE | ||||||||
| MiddleName: | ALYSSA | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PT, DPT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | FERNANDEZ | ||||||||
| OtherFirstName: | KATIE | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 940 S KIMBALL AVE STE 175 | ||||||||
| Address2: | |||||||||
| City: | SOUTHLAKE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 760929024 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8174210034 | ||||||||
| FaxNumber: | 8174210036 | ||||||||
| Practice Location | |||||||||
| Address1: | 419 N KING ST STE 5 | ||||||||
| Address2: | |||||||||
| City: | SEGUIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 781555008 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8303038631 | ||||||||
| FaxNumber: | 8303038541 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/02/2014 | ||||||||
| LastUpdateDate: | 03/23/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/23/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PTH8347 | AL | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 1246473 | TX | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.