Healthcare Provider Details

I. General information

NPI: 1982202487
Provider Name (Legal Business Name): ELIZABETH J MANENTO LPTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/15/2020
Last Update Date: 10/15/2020
Certification Date: 10/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 N MAIN ST
BRISTOL CT
06010-4923
US

IV. Provider business mailing address

155 REDSTONE HILL RD APT 63
BRISTOL CT
06010-7784
US

V. Phone/Fax

Practice location:
  • Phone: 860-584-3400
  • Fax:
Mailing address:
  • Phone: 860-866-6039
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number0009480
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: