Provider Demographics
NPI:1639920119
Name:MANLEY, DWIGHT HANNIBAL (MS)
Entity Type:Individual
Prefix:
First Name:DWIGHT
Middle Name:HANNIBAL
Last Name:MANLEY
Suffix:
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1508 IOLA DR
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31602-3815
Mailing Address - Country:US
Mailing Address - Phone:229-412-2081
Mailing Address - Fax:
Practice Address - Street 1:1508 IOLA DR
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31602-3815
Practice Address - Country:US
Practice Address - Phone:229-412-2081
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-01
Last Update Date:2024-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist