Provider Demographics
NPI:1770863987
Name:MANKUS, CARLY A
Entity Type:Individual
Prefix:
First Name:CARLY
Middle Name:A
Last Name:MANKUS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CARLY
Other - Middle Name:
Other - Last Name:WALKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 346
Mailing Address - Street 2:
Mailing Address - City:NACHES
Mailing Address - State:WA
Mailing Address - Zip Code:98937-0346
Mailing Address - Country:US
Mailing Address - Phone:509-961-0547
Mailing Address - Fax:
Practice Address - Street 1:116 N OAKES AVE STE A2
Practice Address - Street 2:
Practice Address - City:CLE ELUM
Practice Address - State:WA
Practice Address - Zip Code:98922-1273
Practice Address - Country:US
Practice Address - Phone:509-961-0547
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-18
Last Update Date:2020-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
WALW60834632101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health