Provider Demographics
NPI:1508910316
Name:MANLEY, CHARLES STEVEN (PHD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:STEVEN
Last Name:MANLEY
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 1:4100 FAIRWAY DR
Mailing Address - Street 2:STE. 200
Mailing Address - City:CARROLLTON
Mailing Address - State:TX
Mailing Address - Zip Code:75010-6525
Mailing Address - Country:US
Mailing Address - Phone:972-221-1741
Mailing Address - Fax:972-428-2043
Practice Address - Street 1:4100 FAIRWAY DR
Practice Address - Street 2:STE. 200
Practice Address - City:CARROLLTON
Practice Address - State:TX
Practice Address - Zip Code:75010-6525
Practice Address - Country:US
Practice Address - Phone:972-221-1741
Practice Address - Fax:972-428-2043
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-22
Last Update Date:2012-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX23213103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX23213OtherLICENSE