Provider Demographics
NPI:1417541889
Name:PHOTHISATEAN, MANTHANA (PT, DPT)
Entity Type:Individual
Prefix:
First Name:MANTHANA
Middle Name:
Last Name:PHOTHISATEAN
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 BURDA AVE
Mailing Address - Street 2:
Mailing Address - City:NEW CITY
Mailing Address - State:NY
Mailing Address - Zip Code:10956-1418
Mailing Address - Country:US
Mailing Address - Phone:929-928-0986
Mailing Address - Fax:
Practice Address - Street 1:30 BURDA AVE
Practice Address - Street 2:
Practice Address - City:NEW CITY
Practice Address - State:NY
Practice Address - Zip Code:10956-1418
Practice Address - Country:US
Practice Address - Phone:929-928-0986
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-25
Last Update Date:2024-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011579225200000X
NY052136225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant