Provider Demographics
NPI:1053625707
Name:MANDERSON, LOTTOYA JANIEL
Entity type:Individual
Prefix:MS
First Name:LOTTOYA
Middle Name:JANIEL
Last Name:MANDERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3962 SW 188 AVE
Mailing Address - Street 2:
Mailing Address - City:MIRAMAR
Mailing Address - State:FL
Mailing Address - Zip Code:33029
Mailing Address - Country:US
Mailing Address - Phone:917-204-2300
Mailing Address - Fax:
Practice Address - Street 1:3962 SW 188TH AVE
Practice Address - Street 2:
Practice Address - City:MIRAMAR
Practice Address - State:FL
Practice Address - Zip Code:33029-2723
Practice Address - Country:US
Practice Address - Phone:917-204-2300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-04
Last Update Date:2010-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD23223225100000X
NY030647225100000X
TX1182928225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist