Provider Demographics
NPI:1700543840
Name:MANNING, RAQUEL
Entity Type:Individual
Prefix:
First Name:RAQUEL
Middle Name:
Last Name:MANNING
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 1:1390 POLK ST
Mailing Address - Street 2:
Mailing Address - City:BARTOW
Mailing Address - State:FL
Mailing Address - Zip Code:33830-3427
Mailing Address - Country:US
Mailing Address - Phone:863-255-9563
Mailing Address - Fax:
Practice Address - Street 1:1390 POLK ST
Practice Address - Street 2:
Practice Address - City:BARTOW
Practice Address - State:FL
Practice Address - Zip Code:33830-3427
Practice Address - Country:US
Practice Address - Phone:863-255-9563
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-23
Last Update Date:2021-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH19517101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health