Provider Demographics
NPI:1780603787
Name:MANTOOTH, MARY VIVIAN (PT)
Entity type:Individual
Prefix:MRS
First Name:MARY
Middle Name:VIVIAN
Last Name:MANTOOTH
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:VIVIAN
Other - Last Name:HAYDEN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:358 SOUTH MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:LEITCHFIELD
Mailing Address - State:KY
Mailing Address - Zip Code:42754
Mailing Address - Country:US
Mailing Address - Phone:270-259-0551
Mailing Address - Fax:270-230-0009
Practice Address - Street 1:358 S MAIN ST
Practice Address - Street 2:
Practice Address - City:LEITCHFIELD
Practice Address - State:KY
Practice Address - Zip Code:42754-1428
Practice Address - Country:US
Practice Address - Phone:270-259-0551
Practice Address - Fax:270-230-0009
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2007-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPT001004225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY8700064200Medicaid
KY1072857OtherPASSPORT HEALTH
KY000000051788OtherBLUE CROSS BLUE SHIELD
KY000000051788OtherBLUE CROSS BLUE SHIELD