Provider Demographics
NPI:1275072704
Name:MANIGQUE, GLENN
Entity Type:Individual
Prefix:
First Name:GLENN
Middle Name:
Last Name:MANIGQUE
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 1:5889 W VAN GIESEN ST.
Mailing Address - Street 2:APT. 4
Mailing Address - City:WEST RICHLAND
Mailing Address - State:WA
Mailing Address - Zip Code:99353
Mailing Address - Country:US
Mailing Address - Phone:661-616-7184
Mailing Address - Fax:
Practice Address - Street 1:1525 HUNT AVENUE
Practice Address - Street 2:
Practice Address - City:RICHLAND
Practice Address - State:WA
Practice Address - Zip Code:99354
Practice Address - Country:US
Practice Address - Phone:509-967-6250
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-16
Last Update Date:2017-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALL 60728360235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist