Provider Demographics
NPI:1396344453
Name:MANALILI, MICHAEL MOOKIE CRUZ (MA, MTS, MSW, LCSW)
Entity type:Individual
Prefix:MR
First Name:MICHAEL MOOKIE
Middle Name:CRUZ
Last Name:MANALILI
Suffix:
Gender:M
Credentials:MA, MTS, MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:376 MARLBOROUGH ST # 3
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02115-1502
Mailing Address - Country:US
Mailing Address - Phone:818-455-2900
Mailing Address - Fax:
Practice Address - Street 1:354 WASHINGTON ST STE 221
Practice Address - Street 2:
Practice Address - City:WELLESLEY
Practice Address - State:MA
Practice Address - Zip Code:02481-6221
Practice Address - Country:US
Practice Address - Phone:617-435-9762
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-20
Last Update Date:2020-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YP1600X
MA0002260821041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral