Provider Demographics
NPI:1881445112
Name:MANIGAULT, DOLORES M
Entity type:Individual
Prefix:
First Name:DOLORES
Middle Name:M
Last Name:MANIGAULT
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 1:311 E 175TH ST
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10457-5859
Mailing Address - Country:US
Mailing Address - Phone:718-960-7522
Mailing Address - Fax:
Practice Address - Street 1:141 S 3RD ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11211-5509
Practice Address - Country:US
Practice Address - Phone:718-384-6400
Practice Address - Fax:718-388-1651
Is Sole Proprietor?:No
Enumeration Date:2024-03-27
Last Update Date:2024-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY36391101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)