Provider Demographics
NPI:1619479631
Name:MANUEL, MICAH
Entity Type:Individual
Prefix:
First Name:MICAH
Middle Name:
Last Name:MANUEL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:90 GIRARD AVE
Mailing Address - Street 2:72
Mailing Address - City:NEWPORT
Mailing Address - State:RI
Mailing Address - Zip Code:02840-1188
Mailing Address - Country:US
Mailing Address - Phone:401-855-5141
Mailing Address - Fax:
Practice Address - Street 1:90 GIRARD AVE
Practice Address - Street 2:72
Practice Address - City:NEWPORT
Practice Address - State:RI
Practice Address - Zip Code:02840-1188
Practice Address - Country:US
Practice Address - Phone:401-855-5141
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-06
Last Update Date:2018-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst