Provider Demographics
NPI:1942904933
Name:BAEZA, MIA MANZANARES (PT)
Entity Type:Individual
Prefix:
First Name:MIA
Middle Name:MANZANARES
Last Name:BAEZA
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 1:1326 CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:ZACHARY
Mailing Address - State:LA
Mailing Address - Zip Code:70791-2743
Mailing Address - Country:US
Mailing Address - Phone:225-654-8208
Mailing Address - Fax:225-654-4642
Practice Address - Street 1:4027 I 49 S SERVICE RD
Practice Address - Street 2:
Practice Address - City:OPELOUSAS
Practice Address - State:LA
Practice Address - Zip Code:70570-0757
Practice Address - Country:US
Practice Address - Phone:337-948-4212
Practice Address - Fax:337-942-9979
Is Sole Proprietor?:No
Enumeration Date:2023-03-27
Last Update Date:2023-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA11457225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA11457OtherLOUISIANA PHYSICAL THERAPY BOARD