Provider Demographics
NPI:1497095673
Name:MANLEY, EMMANUEL CHRISTIAN SR (LCAS-A)
Entity Type:Individual
Prefix:
First Name:EMMANUEL
Middle Name:CHRISTIAN
Last Name:MANLEY
Suffix:SR
Gender:M
Credentials:LCAS-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4211 FOUR WINDS CT SW
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:NC
Mailing Address - Zip Code:28027-0413
Mailing Address - Country:US
Mailing Address - Phone:803-371-3172
Mailing Address - Fax:
Practice Address - Street 1:4211 FOUR WINDS CT SW
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28027-0413
Practice Address - Country:US
Practice Address - Phone:803-371-3172
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-25
Last Update Date:2013-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC101YA0400X
NC1497095673101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC101YM0800XOther101YM0800X MENTAL HEALTH
NC1497095673Medicaid