Provider Demographics
NPI:1407100498
Name:MEHTA, MANISHA A (LMT)
Entity Type:Individual
Prefix:MRS
First Name:MANISHA
Middle Name:A
Last Name:MEHTA
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11764 HASTINGS BRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:HAMPTON
Mailing Address - State:GA
Mailing Address - Zip Code:30228-6271
Mailing Address - Country:US
Mailing Address - Phone:770-472-8886
Mailing Address - Fax:
Practice Address - Street 1:11764 HASTINGS BRIDGE RD
Practice Address - Street 2:
Practice Address - City:HAMPTON
Practice Address - State:GA
Practice Address - Zip Code:30228-6271
Practice Address - Country:US
Practice Address - Phone:770-472-8886
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-30
Last Update Date:2012-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMT003636225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist