Provider Demographics
NPI:1114183191
Name:MAINELLO, VICKI S (PTA)
Entity Type:Individual
Prefix:MRS
First Name:VICKI
Middle Name:S
Last Name:MAINELLO
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:322 NORTH BUCKMARSH ST.
Mailing Address - Street 2:SUITE A
Mailing Address - City:BERRYVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22611-1025
Mailing Address - Country:US
Mailing Address - Phone:540-955-1837
Mailing Address - Fax:540-955-1838
Practice Address - Street 1:322 NORTH BUCKMARSH ST.
Practice Address - Street 2:SUITE A
Practice Address - City:BERRYVILLE
Practice Address - State:VA
Practice Address - Zip Code:22611-1025
Practice Address - Country:US
Practice Address - Phone:540-955-1837
Practice Address - Fax:540-955-1838
Is Sole Proprietor?:No
Enumeration Date:2008-07-30
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2306001393225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant