Provider Demographics
NPI:1114298791
Name:MANASSERI, MICHELLE (PSYD)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:MANASSERI
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:910 S CHAPEL ST
Mailing Address - Street 2:STE 102
Mailing Address - City:NEWARK
Mailing Address - State:DE
Mailing Address - Zip Code:19713-3467
Mailing Address - Country:US
Mailing Address - Phone:302-224-1400
Mailing Address - Fax:
Practice Address - Street 1:910 S CHAPEL ST
Practice Address - Street 2:STE 102
Practice Address - City:NEWARK
Practice Address - State:DE
Practice Address - Zip Code:19713-3467
Practice Address - Country:US
Practice Address - Phone:302-224-1400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-01-13
Last Update Date:2015-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEB1-0001005103TC0700X, 103G00000X, 103TR0400X
PAPS017616103G00000X, 103TC0700X, 103TR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103TR0400XBehavioral Health & Social Service ProvidersPsychologistRehabilitation