Provider Demographics
NPI:1346288917
Name:CHAKNIS, MANUEL MICHAEL (PHD)
Entity Type:Individual
Prefix:
First Name:MANUEL
Middle Name:MICHAEL
Last Name:CHAKNIS
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2147
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33902-2147
Mailing Address - Country:US
Mailing Address - Phone:239-343-3900
Mailing Address - Fax:239-343-3144
Practice Address - Street 1:2776 CLEVELAND AVE STE 602
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33901-5864
Practice Address - Country:US
Practice Address - Phone:239-343-1614
Practice Address - Fax:239-343-3144
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-03
Last Update Date:2023-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0810003658103G00000X
FLPY0003426103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL116060300Medicaid