Provider Demographics
NPI:1962487371
Name:MANN, MICHAEL T (PT)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:T
Last Name:MANN
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2448 MERRITT CREEK LOOP
Mailing Address - Street 2:
Mailing Address - City:COEUR D'ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-4953
Mailing Address - Country:US
Mailing Address - Phone:208-664-2901
Mailing Address - Fax:208-667-9266
Practice Address - Street 1:2448 MERRITT CREEK LOOP
Practice Address - Street 2:
Practice Address - City:COEUR D'ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-4953
Practice Address - Country:US
Practice Address - Phone:208-664-2901
Practice Address - Fax:208-667-9266
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT-1800225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010153087OtherREGENCE BLUE SHIELD
IDTD355OtherBLUE CROSS OF IDAHO