Provider Demographics
NPI:1326515610
Name:MANTELE, MIKAELA (PTA)
Entity Type:Individual
Prefix:
First Name:MIKAELA
Middle Name:
Last Name:MANTELE
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 1:305 RAINBOW RD
Mailing Address - Street 2:
Mailing Address - City:ELLABELL
Mailing Address - State:GA
Mailing Address - Zip Code:31308-8587
Mailing Address - Country:US
Mailing Address - Phone:303-717-0551
Mailing Address - Fax:
Practice Address - Street 1:101 FAIRVIEW PARK DR
Practice Address - Street 2:
Practice Address - City:DUBLIN
Practice Address - State:GA
Practice Address - Zip Code:31021-2501
Practice Address - Country:US
Practice Address - Phone:478-272-7494
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-25
Last Update Date:2018-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPTA004126225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy AssistantGroup - Single Specialty