Provider Demographics
NPI:1417350521
Name:MANEY, KATIE ALYSSA (PT, DPT)
Entity Type:Individual
Prefix:
First Name:KATIE
Middle Name:ALYSSA
Last Name:MANEY
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:KATIE
Other - Middle Name:
Other - Last Name:FERNANDEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:940 S KIMBALL AVE STE 175
Mailing Address - Street 2:
Mailing Address - City:SOUTHLAKE
Mailing Address - State:TX
Mailing Address - Zip Code:76092-9024
Mailing Address - Country:US
Mailing Address - Phone:817-421-0034
Mailing Address - Fax:817-421-0036
Practice Address - Street 1:419 N KING ST STE 5
Practice Address - Street 2:
Practice Address - City:SEGUIN
Practice Address - State:TX
Practice Address - Zip Code:78155-5008
Practice Address - Country:US
Practice Address - Phone:830-303-8631
Practice Address - Fax:830-303-8541
Is Sole Proprietor?:No
Enumeration Date:2014-10-02
Last Update Date:2020-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALPTH8347225100000X
TX1246473225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX382595YQ3QMedicare PIN
TX382595YQ3QMedicare PIN