Provider Demographics
NPI:1801917158
Name:MANKO, GEORGE JAMES (LICSW)
Entity type:Individual
Prefix:
First Name:GEORGE
Middle Name:JAMES
Last Name:MANKO
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:615 JEFFERSON BLVD
Mailing Address - Street 2:SUITE 208B
Mailing Address - City:WARWICK
Mailing Address - State:RI
Mailing Address - Zip Code:02886-1357
Mailing Address - Country:US
Mailing Address - Phone:401-737-6436
Mailing Address - Fax:401-732-1228
Practice Address - Street 1:615 JEFFERSON BLVD
Practice Address - Street 2:SUITE 208B
Practice Address - City:WARWICK
Practice Address - State:RI
Practice Address - Zip Code:02886-1357
Practice Address - Country:US
Practice Address - Phone:401-737-6436
Practice Address - Fax:401-732-1228
Is Sole Proprietor?:No
Enumeration Date:2007-04-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIISW006311041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI406570OtherBLUE CHIP
RI30185-5OtherBLUE CROSS & BLUE SHIELD
RI1021900OtherBEACON HEALTH STRATEGIES
RI6200364OtherUNITED BEHAVIORAL HEALTH