Provider Demographics
NPI:1295292209
Name:MANRIQUE, KIRBY
Entity type:Individual
Prefix:MR
First Name:KIRBY
Middle Name:
Last Name:MANRIQUE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 HAZLE TOWNSHIP BLVD # 403
Mailing Address - Street 2:
Mailing Address - City:HAZLE TOWNSHIP
Mailing Address - State:PA
Mailing Address - Zip Code:18202-9661
Mailing Address - Country:US
Mailing Address - Phone:570-454-8888
Mailing Address - Fax:
Practice Address - Street 1:401 HAZLE TOWNSHIP BLVD # 403
Practice Address - Street 2:
Practice Address - City:HAZLE TOWNSHIP
Practice Address - State:PA
Practice Address - Zip Code:18202-9661
Practice Address - Country:US
Practice Address - Phone:570-454-8888
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-26
Last Update Date:2019-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOP0009383224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant