Provider Demographics
NPI:1003066788
Name:MANECKE, KRISTEN M (OT)
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:M
Last Name:MANECKE
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4130 LA JOLLA VILLAGE DR
Mailing Address - Street 2:STE 103
Mailing Address - City:LA JOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92037-9121
Mailing Address - Country:US
Mailing Address - Phone:858-455-8584
Mailing Address - Fax:858-455-7302
Practice Address - Street 1:4130 LA JOLLA VILLAGE DR
Practice Address - Street 2:STE 103
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92037-9121
Practice Address - Country:US
Practice Address - Phone:858-455-8584
Practice Address - Fax:858-455-7302
Is Sole Proprietor?:No
Enumeration Date:2008-09-30
Last Update Date:2014-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA2537225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAAY975ZMedicare PIN
CAW17215Medicare PIN