Provider Demographics
NPI:1659467645
Name:MANAHAN, MARY S (MA, CCCA)
Entity type:Individual
Prefix:MRS
First Name:MARY
Middle Name:S
Last Name:MANAHAN
Suffix:
Gender:F
Credentials:MA, CCCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4408 MACCORKLE AVE SE
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25304-2506
Mailing Address - Country:US
Mailing Address - Phone:304-357-9059
Mailing Address - Fax:304-357-4412
Practice Address - Street 1:4408 MACCORKLE AVE SE
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25304-2506
Practice Address - Country:US
Practice Address - Phone:304-357-9059
Practice Address - Fax:304-357-4412
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2015-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVA0198231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WVA0198OtherSTATE LICENSE
WV3403015000Medicaid