Provider Demographics
NPI:1790484996
Name:MANATINE, ALISE
Entity Type:Individual
Prefix:
First Name:ALISE
Middle Name:
Last Name:MANATINE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3492 OAKMONTE BLVD
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:MI
Mailing Address - Zip Code:48306-4789
Mailing Address - Country:US
Mailing Address - Phone:586-907-9516
Mailing Address - Fax:
Practice Address - Street 1:3492 OAKMONTE BLVD
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:MI
Practice Address - Zip Code:48306-4789
Practice Address - Country:US
Practice Address - Phone:586-907-9516
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-27
Last Update Date:2023-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6451022724101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor