=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508469719
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ATHENA MANZINO DPT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/19/2020
-----------------------------------------------------
Last Update Date | 11/19/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 131 KENT RD
-----------------------------------------------------
City | NEW MILFORD
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06776-3485
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 914-584-7778
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 32 PUTNAM LN
-----------------------------------------------------
City | DANBURY
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06810-1515
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 914-584-7778
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 12926
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------