Basic Information
Provider Information | |||||||||
NPI: | 1972797629 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MANLEY | ||||||||
FirstName: | KRISTI | ||||||||
MiddleName: | ANNETTE | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | LMHC LCPC | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | WEAVER | ||||||||
OtherFirstName: | KRISTI | ||||||||
OtherMiddleName: | ANNETTE | ||||||||
OtherNamePrefix: | MRS. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | M.A. C.A.D.C. I | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 2701 17TH ST | ||||||||
Address2: |   | ||||||||
City: | ROCK ISLAND | ||||||||
State: | IL | ||||||||
PostalCode: | 612015351 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3097792031 | ||||||||
FaxNumber: | 3097792167 | ||||||||
Practice Location | |||||||||
Address1: | 2701 17TH ST | ||||||||
Address2: |   | ||||||||
City: | ROCK ISLAND | ||||||||
State: | IL | ||||||||
PostalCode: | 612015351 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3097792031 | ||||||||
FaxNumber: | 3097792167 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/05/2007 | ||||||||
LastUpdateDate: | 06/13/2015 | ||||||||
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 | 101Y00000X |   |   | N |   | Behavioral Health & Social Service Providers | Counselor |   | 101YM0800X |   |   | Y |   | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
ID | Type | State | Issuer | Description | 001087 | 01 | IA | LICENSED MENTAL HEALTH COUNSELOR | OTHER | 180.007471 | 01 | IL | LICENSED CLINICAL PROFESSIONAL COUNSELOR | OTHER |