Provider Demographics
NPI:1164762183
Name:MATTEIS, MANDY (MPT)
Entity Type:Individual
Prefix:
First Name:MANDY
Middle Name:
Last Name:MATTEIS
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 192
Mailing Address - Street 2:
Mailing Address - City:LITHIA
Mailing Address - State:FL
Mailing Address - Zip Code:33547-0192
Mailing Address - Country:US
Mailing Address - Phone:321-848-8730
Mailing Address - Fax:
Practice Address - Street 1:16001 LAKESHORE VILLA DR
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33613-1336
Practice Address - Country:US
Practice Address - Phone:321-848-8730
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-02-28
Last Update Date:2013-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL19149225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist