Provider Demographics
NPI:1477131548
Name:MANLY-SPAIN, FESTINA
Entity Type:Individual
Prefix:
First Name:FESTINA
Middle Name:
Last Name:MANLY-SPAIN
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 1:11843 REGENTS PARK DR
Mailing Address - Street 2:
Mailing Address - City:GERMANTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:20876-2757
Mailing Address - Country:US
Mailing Address - Phone:240-832-0514
Mailing Address - Fax:
Practice Address - Street 1:20410 OBSERVATION DR STE 108
Practice Address - Street 2:
Practice Address - City:GERMANTOWN
Practice Address - State:MD
Practice Address - Zip Code:20876-6419
Practice Address - Country:US
Practice Address - Phone:240-296-5646
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-31
Last Update Date:2021-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD24695104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker