Basic Information
| Provider Information | |||||||||
| NPI: | 1619021672 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MANLOVE | ||||||||
| FirstName: | STEPHEN | ||||||||
| MiddleName: | PAUL | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 636 SAINT ANNE ST | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | RAPID CITY | ||||||||
| State: | SD | ||||||||
| PostalCode: | 577014694 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6053488000 | ||||||||
| FaxNumber: | 6053484315 | ||||||||
| Practice Location | |||||||||
| Address1: | 636 SAINT ANNE ST | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | RAPID CITY | ||||||||
| State: | SD | ||||||||
| PostalCode: | 577014694 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6053488000 | ||||||||
| FaxNumber: | 6053484315 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/23/2007 | ||||||||
| LastUpdateDate: | 10/29/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 10/29/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | 1887 | SD | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 6003470 | 05 | SD | MEDICAID |