Provider Demographics
NPI:1912239419
Name:MANELY KIDS
Entity Type:Organization
Organization Name:MANELY KIDS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ANNETTE
Authorized Official - Middle Name:M
Authorized Official - Last Name:CRENSHAW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-923-1088
Mailing Address - Street 1:215 JEP WHEELER RD
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:GA
Mailing Address - Zip Code:30188-6501
Mailing Address - Country:US
Mailing Address - Phone:678-923-1088
Mailing Address - Fax:
Practice Address - Street 1:347 ARNOLD MILL RD
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:GA
Practice Address - Zip Code:30188-2835
Practice Address - Country:US
Practice Address - Phone:678-923-1088
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-08
Last Update Date:2010-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0614616225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA720022501AMedicaid