Provider Demographics
NPI:1053878587
Name:MANUEL, MARY KATE (COTA/L)
Entity type:Individual
Prefix:MRS
First Name:MARY
Middle Name:KATE
Last Name:MANUEL
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31 CAPE CHARLES SQ
Mailing Address - Street 2:
Mailing Address - City:LYNCHBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24502-4395
Mailing Address - Country:US
Mailing Address - Phone:434-941-1537
Mailing Address - Fax:
Practice Address - Street 1:1613 OAKWOOD ST
Practice Address - Street 2:
Practice Address - City:BEDFORD
Practice Address - State:VA
Practice Address - Zip Code:24523-1213
Practice Address - Country:US
Practice Address - Phone:540-425-7863
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-20
Last Update Date:2019-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0131001639208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty