Healthcare Provider Details

I. General information

NPI: 1851863047
Provider Name (Legal Business Name): AMANDA MANGULABNAN PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: AMANDA CASH PTA

II. Dates (important events)

Enumeration Date: 12/28/2018
Last Update Date: 12/28/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 W MAIN ST
FREEHOLD NJ
07728-2537
US

IV. Provider business mailing address

889 GREGORY DR
BRICK NJ
08723-6207
US

V. Phone/Fax

Practice location:
  • Phone: 732-294-2700
  • Fax: 732-294-2568
Mailing address:
  • Phone: 848-459-6094
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number40QB00298400
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: