Provider Demographics
NPI:1952683542
Name:MANCILLAS-LOVELESS, MARY DOLORES (PTA, LMT, CPED)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:DOLORES
Last Name:MANCILLAS-LOVELESS
Suffix:
Gender:F
Credentials:PTA, LMT, CPED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3026 4TH AVENUE SOUTH
Mailing Address - Street 2:
Mailing Address - City:GREAT FALLS
Mailing Address - State:MT
Mailing Address - Zip Code:59405-3330
Mailing Address - Country:US
Mailing Address - Phone:406-750-2655
Mailing Address - Fax:
Practice Address - Street 1:612 1ST AVE. SO.
Practice Address - Street 2:
Practice Address - City:GREAT FALLS
Practice Address - State:MT
Practice Address - Zip Code:59401
Practice Address - Country:US
Practice Address - Phone:406-750-2655
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-09
Last Update Date:2011-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT1096225200000X
MT568225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist