Provider Demographics
NPI:1164047809
Name:MANRIQUE, MANUEL ARMANDO
Entity Type:Individual
Prefix:MR
First Name:MANUEL
Middle Name:ARMANDO
Last Name:MANRIQUE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12438 BRANTLEY COMMONS CT
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33907-5683
Mailing Address - Country:US
Mailing Address - Phone:239-349-3139
Mailing Address - Fax:239-984-4372
Practice Address - Street 1:12438 BRANTLEY COMMONS CT
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33907-5683
Practice Address - Country:US
Practice Address - Phone:239-349-3139
Practice Address - Fax:239-349-3139
Is Sole Proprietor?:No
Enumeration Date:2020-06-09
Last Update Date:2021-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-20-119708106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician