Provider Demographics
NPI:1972162402
Name:MANALAC-KWASNA, ALEC (MA)
Entity Type:Individual
Prefix:
First Name:ALEC
Middle Name:
Last Name:MANALAC-KWASNA
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:340 E 1ST AVE STE 300
Mailing Address - Street 2:
Mailing Address - City:BROOMFIELD
Mailing Address - State:CO
Mailing Address - Zip Code:80020-2454
Mailing Address - Country:US
Mailing Address - Phone:631-742-9443
Mailing Address - Fax:
Practice Address - Street 1:340 E 1ST AVE STE 300
Practice Address - Street 2:
Practice Address - City:BROOMFIELD
Practice Address - State:CO
Practice Address - Zip Code:80020-2454
Practice Address - Country:US
Practice Address - Phone:631-742-9443
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-09
Last Update Date:2023-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
CONLC.0110197101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty