Provider Demographics
NPI:1740370477
Name:MANTHEY, TALI MARIE (MPT)
Entity type:Individual
Prefix:
First Name:TALI
Middle Name:MARIE
Last Name:MANTHEY
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30099 RESERVOIR AVE
Mailing Address - Street 2:
Mailing Address - City:NUEVO
Mailing Address - State:CA
Mailing Address - Zip Code:92567-9779
Mailing Address - Country:US
Mailing Address - Phone:951-928-0773
Mailing Address - Fax:951-928-2535
Practice Address - Street 1:30099 RESERVOIR AVE
Practice Address - Street 2:
Practice Address - City:NUEVO
Practice Address - State:CA
Practice Address - Zip Code:92567-9779
Practice Address - Country:US
Practice Address - Phone:951-928-0773
Practice Address - Fax:951-928-2535
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2012-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA25665225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0PT256650Medicare PIN