1659467645 NPI number — MRS. MARY S MANAHAN MA, CCCA

Table of content: MRS. MARY S MANAHAN MA, CCCA (NPI 1659467645)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1659467645 NPI number — MRS. MARY S MANAHAN MA, CCCA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MANAHAN
Provider First Name:
MARY
Provider Middle Name:
S
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
MA, CCCA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1659467645
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/14/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4408 MACCORKLE AVE SE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHARLESTON
Provider Business Mailing Address State Name:
WV
Provider Business Mailing Address Postal Code:
25304-2506
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
304-357-9059
Provider Business Mailing Address Fax Number:
304-357-4412

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4408 MACCORKLE AVE SE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHARLESTON
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
25304-2506
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-357-9059
Provider Business Practice Location Address Fax Number:
304-357-4412
Provider Enumeration Date:
10/05/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 231H00000X , with the licence number:  A0198 , registered in the state of WV ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: A0198 . This is a "STATE LICENSE" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".
  • Identifier: 3403015000 , issued by the state of ( WV ) . This identifiers is of the category "MEDICAID".