Provider Demographics
NPI:1528375607
Name:MANLEY, JUSTYN HASKELL (JUSTYN MANLEY)
Entity Type:Individual
Prefix:MRS
First Name:JUSTYN
Middle Name:HASKELL
Last Name:MANLEY
Suffix:
Gender:F
Credentials:JUSTYN MANLEY
Other - Prefix:
Other - First Name:JUSTYN
Other - Middle Name:
Other - Last Name:HASKELL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW
Mailing Address - Street 1:8947 N PROMONTORY RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:PARK CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84098-5786
Mailing Address - Country:US
Mailing Address - Phone:435-640-1327
Mailing Address - Fax:
Practice Address - Street 1:1912 SIDEWINDER DR STE 201
Practice Address - Street 2:
Practice Address - City:PARK CITY
Practice Address - State:UT
Practice Address - Zip Code:84060-7257
Practice Address - Country:US
Practice Address - Phone:435-640-1327
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-09
Last Update Date:2019-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8262078-3502104100000X
UT8262078-35011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker