Basic Information
| Provider Information | |||||||||
| NPI: | 1003146978 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MANZANO | ||||||||
| FirstName: | KELLI | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LCSW-C, LICSW | ||||||||
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| 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 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 17093 | MD | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 1041C0700X | DP00944880 | WV | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.