Provider Demographics
NPI:1114257755
Name:MANZ, MARY V (PTA)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:V
Last Name:MANZ
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 1:2940 N CLINTON ST
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46805-1910
Mailing Address - Country:US
Mailing Address - Phone:260-484-7988
Mailing Address - Fax:
Practice Address - Street 1:2940 N CLINTON ST
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46805-1910
Practice Address - Country:US
Practice Address - Phone:260-484-7988
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-04
Last Update Date:2010-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN06003877A225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant