Provider Demographics
NPI:1912415001
Name:MANLEY, VIRGINIA M (RBT)
Entity Type:Individual
Prefix:
First Name:VIRGINIA
Middle Name:M
Last Name:MANLEY
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:709 PACKARD PL
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28311-2527
Mailing Address - Country:US
Mailing Address - Phone:808-838-9610
Mailing Address - Fax:
Practice Address - Street 1:6985 NEXUS CT STE 107
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28304-3186
Practice Address - Country:US
Practice Address - Phone:910-728-4449
Practice Address - Fax:910-728-4644
Is Sole Proprietor?:No
Enumeration Date:2018-01-11
Last Update Date:2018-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1790129740106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician