Provider Demographics
NPI:1790819936
Name:BRITTSAN, MANDA LANE (PT)
Entity Type:Individual
Prefix:
First Name:MANDA
Middle Name:LANE
Last Name:BRITTSAN
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 1:1790 SW 43RD WAY
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33317-5701
Mailing Address - Country:US
Mailing Address - Phone:855-442-2454
Mailing Address - Fax:954-206-7699
Practice Address - Street 1:1790 SW 43RD WAY
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33317-5701
Practice Address - Country:US
Practice Address - Phone:855-442-2454
Practice Address - Fax:954-206-7699
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-16
Last Update Date:2018-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT007712225100000X
FLPT27119225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist