Individual
MRS. MARY VIVIAN MANTOOTH
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
PT
Contact information
Practice address
358 S MAIN ST, LEITCHFIELD, KY 42754-1428
(270) 259-0551
(270) 230-0009
Mailing address
358 SOUTH MAIN STREET, LEITCHFIELD, KY 42754
(270) 259-0551
(270) 230-0009
Taxonomy
Speciality
Code
Description
License number
State
225100000X
Physical Therapist
Primary
PT001004
KY
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000000051788
BLUE CROSS BLUE SHIELD
KY
01
—
1072857
PASSPORT HEALTH
KY
05
—
8700064200
—
KY
Enumeration date
07/19/2006
Last updated
12/06/2007
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