Provider Demographics
NPI:1164002762
Name:MANAOG, MARIE JOYCE HERRERA
Entity Type:Individual
Prefix:
First Name:MARIE JOYCE
Middle Name:HERRERA
Last Name:MANAOG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:224 MEELER CIR
Mailing Address - Street 2:
Mailing Address - City:BOGART
Mailing Address - State:GA
Mailing Address - Zip Code:30622-6835
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:224 MEELER CIR
Practice Address - Street 2:
Practice Address - City:BOGART
Practice Address - State:GA
Practice Address - Zip Code:30622-6835
Practice Address - Country:US
Practice Address - Phone:213-359-7786
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-09
Last Update Date:2021-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT011862225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist