Provider Demographics
NPI:1336158344
Name:SANTA TERESA, MARYGENE MANANSALA (MD)
Entity Type:Individual
Prefix:
First Name:MARYGENE
Middle Name:MANANSALA
Last Name:SANTA TERESA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:41 EMILY LN
Mailing Address - Street 2:
Mailing Address - City:WARWICK
Mailing Address - State:RI
Mailing Address - Zip Code:02886-4527
Mailing Address - Country:US
Mailing Address - Phone:201-647-9831
Mailing Address - Fax:401-276-4111
Practice Address - Street 1:530 NORTH MAIN STREET
Practice Address - Street 2:THE PROVIDENCE CENTER
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02904
Practice Address - Country:US
Practice Address - Phone:401-528-0110
Practice Address - Fax:401-276-4111
Is Sole Proprietor?:No
Enumeration Date:2006-08-07
Last Update Date:2011-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0416492084P0800X
RI115972084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTI00004Medicare UPIN