Provider Demographics
NPI:1003245564
Name:MANRIQUE, KIMBERLY (MS, LPC, ATR)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:MANRIQUE
Suffix:
Gender:F
Credentials:MS, LPC, ATR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5798 DEER TRAIL DR
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-8479
Mailing Address - Country:US
Mailing Address - Phone:231-709-3177
Mailing Address - Fax:
Practice Address - Street 1:5798 DEER TRAIL DR
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-8479
Practice Address - Country:US
Practice Address - Phone:231-709-3177
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-11-05
Last Update Date:2013-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH950101YM0800X
MI6401013605101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health