Provider Demographics
NPI:1134957129
Name:MANKIN, CLARISSA YVONNE
Entity type:Individual
Prefix:
First Name:CLARISSA
Middle Name:YVONNE
Last Name:MANKIN
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 1:224 MARILEE DR
Mailing Address - Street 2:
Mailing Address - City:NEW LEBANON
Mailing Address - State:OH
Mailing Address - Zip Code:45345-1449
Mailing Address - Country:US
Mailing Address - Phone:937-732-1930
Mailing Address - Fax:
Practice Address - Street 1:228 N BARRON ST
Practice Address - Street 2:
Practice Address - City:EATON
Practice Address - State:OH
Practice Address - Zip Code:45320-1704
Practice Address - Country:US
Practice Address - Phone:937-456-7694
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-23
Last Update Date:2024-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YS0200X
OHRA164223405300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool
No405300000XOther Service ProvidersPrevention Professional