Provider Demographics
NPI:1083620082
Name:MANDERSON, MARY ELIZABETH (PT)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ELIZABETH
Last Name:MANDERSON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 THRASHER WAY
Mailing Address - Street 2:
Mailing Address - City:EL CAJON
Mailing Address - State:CA
Mailing Address - Zip Code:92020-2632
Mailing Address - Country:US
Mailing Address - Phone:619-469-0810
Mailing Address - Fax:
Practice Address - Street 1:1246 E MAIN ST STE 109
Practice Address - Street 2:
Practice Address - City:EL CAJON
Practice Address - State:CA
Practice Address - Zip Code:92021-7206
Practice Address - Country:US
Practice Address - Phone:619-441-1200
Practice Address - Fax:619-441-1215
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2018-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA158742251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics