Provider Demographics
NPI:1275936429
Name:MANNARINO, ANDREA GAIL (COTA)
Entity Type:Individual
Prefix:MRS
First Name:ANDREA
Middle Name:GAIL
Last Name:MANNARINO
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:629 SLADE WOODWARD RD
Mailing Address - Street 2:
Mailing Address - City:POPLARVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:39470-7157
Mailing Address - Country:US
Mailing Address - Phone:228-363-3116
Mailing Address - Fax:
Practice Address - Street 1:629 SLADE WOODWARD RD
Practice Address - Street 2:
Practice Address - City:POPLARVILLE
Practice Address - State:MS
Practice Address - Zip Code:39470-7157
Practice Address - Country:US
Practice Address - Phone:228-363-3116
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-02
Last Update Date:2014-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSTA2953224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant