Basic Information
| Provider Information | |||||||||
| NPI: | 1427381961 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MANALASTAS | ||||||||
| FirstName: | KATHLEEN | ||||||||
| MiddleName: | SUSANNE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DPT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BANNISTER | ||||||||
| OtherFirstName: | KATHLEEN | ||||||||
| OtherMiddleName: | SUSANNE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | DPT | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1838 GREEN TREE ROAD | ||||||||
| Address2: | SUITE 290 | ||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 21208 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4106539813 | ||||||||
| FaxNumber: | 4106539815 | ||||||||
| Practice Location | |||||||||
| Address1: | 1838 GREEN TREE ROAD | ||||||||
| Address2: | SUITE 290 | ||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 21208 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4106539813 | ||||||||
| FaxNumber: | 4106539815 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/16/2009 | ||||||||
| LastUpdateDate: | 04/25/2011 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 23263 | MD | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 031542 | NY | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.