Provider Demographics
NPI:1639238975
Name:MANNIELLO, KRISTINA ELLEN (OT)
Entity Type:Individual
Prefix:
First Name:KRISTINA
Middle Name:ELLEN
Last Name:MANNIELLO
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:KRISTINA
Other - Middle Name:E
Other - Last Name:LACROIX
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OT
Mailing Address - Street 1:1022 MOUNT WHITNEY DR
Mailing Address - Street 2:
Mailing Address - City:SUMMERVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29483-3318
Mailing Address - Country:US
Mailing Address - Phone:413-949-0986
Mailing Address - Fax:
Practice Address - Street 1:1022 MOUNT WHITNEY DR
Practice Address - Street 2:
Practice Address - City:SUMMERVILLE
Practice Address - State:SC
Practice Address - Zip Code:29483-3318
Practice Address - Country:US
Practice Address - Phone:413-949-0986
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-06
Last Update Date:2021-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA3313225XH1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
No225XH1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistHand
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0359068Medicaid
MAY68644Medicare ID - Type Unspecified
MA5850470001Medicare NSC