Provider Demographics
NPI:1508113382
Name:MANTANONA, SELINA THERESE (PT, DPT)
Entity Type:Individual
Prefix:
First Name:SELINA
Middle Name:THERESE
Last Name:MANTANONA
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 1:928 MAR WALT DR
Mailing Address - Street 2:SUITE #103
Mailing Address - City:FORT WALTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32547-6706
Mailing Address - Country:US
Mailing Address - Phone:850-863-7580
Mailing Address - Fax:850-863-7549
Practice Address - Street 1:928 MAR WALT DR
Practice Address - Street 2:SUITE #103
Practice Address - City:FORT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32547-6706
Practice Address - Country:US
Practice Address - Phone:850-863-7580
Practice Address - Fax:850-863-7549
Is Sole Proprietor?:No
Enumeration Date:2012-08-10
Last Update Date:2016-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070018813225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist