Provider Demographics
NPI:1659411254
Name:MANOR, DIANA (MS)
Entity Type:Individual
Prefix:MRS
First Name:DIANA
Middle Name:
Last Name:MANOR
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:DIANA
Other - Middle Name:
Other - Last Name:LISH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:400 CLUBHOUSE COURT
Mailing Address - Street 2:
Mailing Address - City:CORAM
Mailing Address - State:NY
Mailing Address - Zip Code:11727
Mailing Address - Country:US
Mailing Address - Phone:631-736-6643
Mailing Address - Fax:631-736-6643
Practice Address - Street 1:1919 MIDDLE COUNTRY ROAD
Practice Address - Street 2:SUITE 201
Practice Address - City:CENTEREACH
Practice Address - State:NY
Practice Address - Zip Code:11720
Practice Address - Country:US
Practice Address - Phone:631-921-2208
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY002783101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health