Basic Information
Provider Information | |||||||||
NPI: | 1043820913 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MANELA | ||||||||
FirstName: | ELIZABETH | ||||||||
MiddleName: | ANN | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | SLP CCC | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2075 EAST WEST MAPLE ROAD | ||||||||
Address2: | SUITE B203 | ||||||||
City: | WALLED LAKE | ||||||||
State: | MI | ||||||||
PostalCode: | 48390 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2489260909 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 2075 EAST WEST MAPLE ROAD | ||||||||
Address2: | SUITE B203 | ||||||||
City: | WALLED LAKE | ||||||||
State: | MI | ||||||||
PostalCode: | 48390 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2489260909 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/05/2020 | ||||||||
LastUpdateDate: | 08/05/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 08/05/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | 7101000277 | MI | Y |   | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |   |
No ID Information.