Provider Demographics
NPI:1619513926
Name:MANDILE, SUZANNE MAYNARD (PT)
Entity Type:Individual
Prefix:
First Name:SUZANNE
Middle Name:MAYNARD
Last Name:MANDILE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13 MUSTER LN
Mailing Address - Street 2:
Mailing Address - City:LEDYARD
Mailing Address - State:CT
Mailing Address - Zip Code:06339-1735
Mailing Address - Country:US
Mailing Address - Phone:860-883-9566
Mailing Address - Fax:
Practice Address - Street 1:427 9TH ST
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78215-1528
Practice Address - Country:US
Practice Address - Phone:210-951-3280
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-21
Last Update Date:2019-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT3735225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT3735OtherPHYSICAL THERAPY LICENSE