Provider Demographics
NPI:1689148801
Name:MANATT, ROBBY XAVIER (PT,DPT)
Entity Type:Individual
Prefix:MR
First Name:ROBBY
Middle Name:XAVIER
Last Name:MANATT
Suffix:
Gender:M
Credentials:PT,DPT
Other - Prefix:
Other - First Name:MANATT
Other - Middle Name:ROBBY
Other - Last Name:XAVIER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT,DPT
Mailing Address - Street 1:548 GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:LEONIA
Mailing Address - State:NJ
Mailing Address - Zip Code:07605-2111
Mailing Address - Country:US
Mailing Address - Phone:973-900-0460
Mailing Address - Fax:
Practice Address - Street 1:7624 SPRINGFIELD BLVD
Practice Address - Street 2:# 147B1
Practice Address - City:BAYSIDE
Practice Address - State:NY
Practice Address - Zip Code:11364-3023
Practice Address - Country:US
Practice Address - Phone:973-900-0460
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-22
Last Update Date:2021-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY028342225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
14394752OtherCAQH