Provider Demographics
NPI:1821593237
Name:MCMANAMY, EVAN
Entity type:Individual
Prefix:
First Name:EVAN
Middle Name:
Last Name:MCMANAMY
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 1:433 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02909-1624
Mailing Address - Country:US
Mailing Address - Phone:401-680-0334
Mailing Address - Fax:
Practice Address - Street 1:433 BROADWAY
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02909-1624
Practice Address - Country:US
Practice Address - Phone:401-680-0334
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-27
Last Update Date:2022-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60845227225700000X
RIMT02510225700000X
RICSW027411041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist