Provider Demographics
NPI:1639209513
Name:MAHANEY, KRISTA MARIE (PT)
Entity Type:Individual
Prefix:
First Name:KRISTA
Middle Name:MARIE
Last Name:MAHANEY
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 1:827 S CHARLES ST
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21230-3938
Mailing Address - Country:US
Mailing Address - Phone:410-962-5344
Mailing Address - Fax:
Practice Address - Street 1:1450 FURNACE AVE
Practice Address - Street 2:
Practice Address - City:GLEN BURNIE
Practice Address - State:MD
Practice Address - Zip Code:21060-7002
Practice Address - Country:US
Practice Address - Phone:410-222-6911
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD19318225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD5553Medicaid