Provider Demographics
NPI:1356947089
Name:DEIDRE MANIS, LLC
Entity type:Organization
Organization Name:DEIDRE MANIS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL SOCIAL WORKER
Authorized Official - Prefix:
Authorized Official - First Name:DEIDRE
Authorized Official - Middle Name:
Authorized Official - Last Name:MANIS
Authorized Official - Suffix:
Authorized Official - Credentials:LSCSW, LCAC
Authorized Official - Phone:620-875-9656
Mailing Address - Street 1:1041 N MEADOW RD
Mailing Address - Street 2:
Mailing Address - City:VALLEY CENTER
Mailing Address - State:KS
Mailing Address - Zip Code:67147-9400
Mailing Address - Country:US
Mailing Address - Phone:620-875-9656
Mailing Address - Fax:316-636-1190
Practice Address - Street 1:7807 E FUNSTON ST
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67207-3123
Practice Address - Country:US
Practice Address - Phone:316-636-1188
Practice Address - Fax:316-636-1190
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-12-08
Last Update Date:2020-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health