Provider Demographics
NPI:1528394087
Name:MANNETTI, MARK A (PT)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:A
Last Name:MANNETTI
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 751803
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28275-1803
Mailing Address - Country:US
Mailing Address - Phone:336-996-7001
Mailing Address - Fax:336-996-0832
Practice Address - Street 1:1903 S HAWTHORNE RD
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-3916
Practice Address - Country:US
Practice Address - Phone:336-996-7001
Practice Address - Fax:336-996-0832
Is Sole Proprietor?:No
Enumeration Date:2009-10-19
Last Update Date:2009-10-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC12384225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist