Basic Information
Provider Information
NPI: 1003146978
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: MANZANO
FirstName: KELLI
MiddleName: ANN
NamePrefix: MRS.
NameSuffix:  
Credential: LCSW-C, LICSW
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 142 N QUEEN ST
Address2:  
City: MARTINSBURG
State: WV
PostalCode: 254013312
CountryCode: US
TelephoneNumber: 3045960486
FaxNumber: 3047605945
Practice Location
Address1: 142 N QUEEN ST
Address2:  
City: MARTINSBURG
State: WV
PostalCode: 25401
CountryCode: US
TelephoneNumber: 3045960486
FaxNumber: 3047605945
Other Information
ProviderEnumerationDate: 12/28/2009
LastUpdateDate: 06/13/2018
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
1041C0700XDP00944880WVY Behavioral Health & Social Service ProvidersSocial WorkerClinical
1041C0700X17093MDN Behavioral Health & Social Service ProvidersSocial WorkerClinical

No ID Information.


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