Basic Information
| Provider Information | |||||||||
| NPI: | 1477907483 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MANNING | ||||||||
| FirstName: | CATHLEEN | ||||||||
| MiddleName: | KEZELL | ||||||||
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| Credential: | MPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 430 INNOVATION DR | ||||||||
| Address2: | |||||||||
| City: | BLAIRSVILLE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 157178096 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7243434060 | ||||||||
| FaxNumber: | 7243434069 | ||||||||
| Practice Location | |||||||||
| Address1: | 196 MATCH FACTORY PL | ||||||||
| Address2: | |||||||||
| City: | BELLEFONTE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 168231367 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8143553561 | ||||||||
| FaxNumber: | 8143538235 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/15/2016 | ||||||||
| LastUpdateDate: | 04/15/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT002747E | PA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 1019541330001 | 05 | PA | MEDICAID |