Provider Demographics
NPI:1649931015
Name:MANSWELL, MYKAL
Entity type:Individual
Prefix:
First Name:MYKAL
Middle Name:
Last Name:MANSWELL
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 1:4712 SUMMIT OVERLOOK DR APT 103
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27612-2938
Mailing Address - Country:US
Mailing Address - Phone:443-468-0629
Mailing Address - Fax:
Practice Address - Street 1:8406 SIX FORKS RD STE 104
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27615-3075
Practice Address - Country:US
Practice Address - Phone:919-424-6045
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-06
Last Update Date:2022-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA17194101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty