Provider Demographics
NPI:1356538102
Name:MANNERAAK, MICHAEL J (PT, MRS-PT)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:J
Last Name:MANNERAAK
Suffix:
Gender:M
Credentials:PT, MRS-PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2125 CHARLIE HALL BLVD
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29414-5879
Mailing Address - Country:US
Mailing Address - Phone:843-573-1513
Mailing Address - Fax:843-573-1511
Practice Address - Street 1:2125 CHARLIE HALL BLVD
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29414-5879
Practice Address - Country:US
Practice Address - Phone:843-573-1513
Practice Address - Fax:843-573-1511
Is Sole Proprietor?:No
Enumeration Date:2007-09-26
Last Update Date:2007-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4126225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist