Provider Demographics
NPI:1477926079
Name:MUTCHERSON-MANOR, ROVENIA
Entity Type:Individual
Prefix:
First Name:ROVENIA
Middle Name:
Last Name:MUTCHERSON-MANOR
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9425 QUILL PL
Mailing Address - Street 2:
Mailing Address - City:GAITHERSBURG
Mailing Address - State:MD
Mailing Address - Zip Code:20886-1245
Mailing Address - Country:US
Mailing Address - Phone:301-325-0568
Mailing Address - Fax:
Practice Address - Street 1:9425 QUILL PL
Practice Address - Street 2:
Practice Address - City:GAITHERSBURG
Practice Address - State:MD
Practice Address - Zip Code:20886-1245
Practice Address - Country:US
Practice Address - Phone:301-325-0568
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-11-04
Last Update Date:2015-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD21021225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist