Provider Demographics
NPI:1235800053
Name:MANAHAN, MORIAH CONSTANCE
Entity Type:Individual
Prefix:
First Name:MORIAH
Middle Name:CONSTANCE
Last Name:MANAHAN
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 1:263 KING RD
Mailing Address - Street 2:
Mailing Address - City:BAKERSFIELD
Mailing Address - State:VT
Mailing Address - Zip Code:05441-9749
Mailing Address - Country:US
Mailing Address - Phone:802-752-5130
Mailing Address - Fax:
Practice Address - Street 1:174 AVENUE C
Practice Address - Street 2:
Practice Address - City:WILLISTON
Practice Address - State:VT
Practice Address - Zip Code:05495-7840
Practice Address - Country:US
Practice Address - Phone:802-662-7831
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-22
Last Update Date:2021-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT1470123010106E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst