Provider Demographics
NPI:1295139251
Name:MICHELLE M. MANASSERI PSYD LLC
Entity type:Organization
Organization Name:MICHELLE M. MANASSERI PSYD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:MANASSERI
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:302-478-1578
Mailing Address - Street 1:1125 CRESTOVER RD
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:DE
Mailing Address - Zip Code:19803-3308
Mailing Address - Country:US
Mailing Address - Phone:302-385-6228
Mailing Address - Fax:
Practice Address - Street 1:910 S CHAPEL ST
Practice Address - Street 2:STE 201
Practice Address - City:NEWARK
Practice Address - State:DE
Practice Address - Zip Code:19713-3467
Practice Address - Country:US
Practice Address - Phone:302-224-1400
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-20
Last Update Date:2015-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS017616103G00000X, 103TC0700X, 103TR0400X
DEB1-0001005103G00000X, 103TR0400X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Multi-Specialty
No103TR0400XBehavioral Health & Social Service ProvidersPsychologistRehabilitationGroup - Multi-Specialty