Provider Demographics
NPI:1932644671
Name:MANISE, BRUCE (EDM, MA)
Entity Type:Individual
Prefix:MR
First Name:BRUCE
Middle Name:
Last Name:MANISE
Suffix:
Gender:M
Credentials:EDM, MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2203 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22182-5102
Mailing Address - Country:US
Mailing Address - Phone:703-582-0023
Mailing Address - Fax:
Practice Address - Street 1:131 PARK ST NE # 8
Practice Address - Street 2:
Practice Address - City:VIENNA
Practice Address - State:VA
Practice Address - Zip Code:22180-4641
Practice Address - Country:US
Practice Address - Phone:703-582-0023
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-05
Last Update Date:2017-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701003313101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0701003313OtherLICENSED PROFESSIONAL COUNSELOR