Provider Demographics
NPI:1356901151
Name:MANALAC, DINA
Entity type:Individual
Prefix:
First Name:DINA
Middle Name:
Last Name:MANALAC
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 1:675 LAKE ST APT 230
Mailing Address - Street 2:
Mailing Address - City:OAK PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60301-1409
Mailing Address - Country:US
Mailing Address - Phone:615-440-1500
Mailing Address - Fax:
Practice Address - Street 1:5425 W 31ST ST
Practice Address - Street 2:
Practice Address - City:CICERO
Practice Address - State:IL
Practice Address - Zip Code:60804-3989
Practice Address - Country:US
Practice Address - Phone:615-440-1500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-14
Last Update Date:2024-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician