Provider Demographics
NPI:1790259562
Name:MANCILLA, DOUGLAS (PT, DPT)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:
Last Name:MANCILLA
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21756 STATE ROAD 54
Mailing Address - Street 2:STE 102
Mailing Address - City:LUTZ
Mailing Address - State:FL
Mailing Address - Zip Code:33549-2905
Mailing Address - Country:US
Mailing Address - Phone:727-475-5540
Mailing Address - Fax:
Practice Address - Street 1:3180 CURLEW RD
Practice Address - Street 2:
Practice Address - City:OLDSMAR
Practice Address - State:FL
Practice Address - Zip Code:34677-2629
Practice Address - Country:US
Practice Address - Phone:813-343-4840
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-15
Last Update Date:2022-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT34144225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPT34144OtherPT LICENSE