Basic Information
Provider Information | |||||||||
NPI: | 1730317959 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MANNING | ||||||||
FirstName: | CHANTALE | ||||||||
MiddleName: | EVA | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | SLP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | WINSTON | ||||||||
OtherFirstName: | CHANTALE | ||||||||
OtherMiddleName: | EVA | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 2 | ||||||||
Mailing Information | |||||||||
Address1: | 1259 CHINON PT | ||||||||
Address2: |   | ||||||||
City: | LITHONIA | ||||||||
State: | GA | ||||||||
PostalCode: | 300587058 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5013283733 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 2915 S HAZEL ST | ||||||||
Address2: |   | ||||||||
City: | PINE BLUFF | ||||||||
State: | AR | ||||||||
PostalCode: | 716035008 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8705350010 | ||||||||
FaxNumber: | 8705351116 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/25/2009 | ||||||||
LastUpdateDate: | 12/28/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | SP#P8101 | AR | N |   | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |   | 235Z00000X | SLP008185 | GA | Y |   | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |   |
No ID Information.