Provider Demographics
NPI:1215360490
Name:MANIS, MATTHEW BLAKE (PHD, BA, CLC)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:BLAKE
Last Name:MANIS
Suffix:
Gender:M
Credentials:PHD, BA, CLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:119 CHESTERFIELD CIR
Mailing Address - Street 2:
Mailing Address - City:WAXAHACHIE
Mailing Address - State:TX
Mailing Address - Zip Code:75165-6362
Mailing Address - Country:US
Mailing Address - Phone:214-230-1621
Mailing Address - Fax:972-935-0930
Practice Address - Street 1:1601 HWY 77 N.
Practice Address - Street 2:
Practice Address - City:WAXAHACHIE
Practice Address - State:TX
Practice Address - Zip Code:75165
Practice Address - Country:US
Practice Address - Phone:214-230-1621
Practice Address - Fax:972-935-0930
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-12
Last Update Date:2013-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health