Provider Demographics
NPI:1679857171
Name:MANALO, MICHAEL JAY (PHD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:JAY
Last Name:MANALO
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:45 SOUTH AVE SE
Mailing Address - Street 2:STE 100
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30060-2539
Mailing Address - Country:US
Mailing Address - Phone:770-423-7500
Mailing Address - Fax:678-909-0294
Practice Address - Street 1:45 SOUTH AVE SE
Practice Address - Street 2:STE 100
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30060-2539
Practice Address - Country:US
Practice Address - Phone:770-423-7500
Practice Address - Fax:678-909-0294
Is Sole Proprietor?:No
Enumeration Date:2011-10-03
Last Update Date:2012-09-12
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GAPSY003588103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling