Provider Demographics
NPI:1841587086
Name:MANTEGAZZA, RENA MULLER (PT)
Entity Type:Individual
Prefix:
First Name:RENA
Middle Name:MULLER
Last Name:MANTEGAZZA
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 1:38 MADELINE DR
Mailing Address - Street 2:
Mailing Address - City:RIDGEFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06877-2209
Mailing Address - Country:US
Mailing Address - Phone:203-438-0343
Mailing Address - Fax:
Practice Address - Street 1:13 PARK LAWN DR
Practice Address - Street 2:
Practice Address - City:BETHEL
Practice Address - State:CT
Practice Address - Zip Code:06801-1043
Practice Address - Country:US
Practice Address - Phone:203-830-4180
Practice Address - Fax:203-797-2995
Is Sole Proprietor?:No
Enumeration Date:2011-07-08
Last Update Date:2011-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT003292225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist