Healthcare Provider Details

I. General information

NPI: 1114043155
Provider Name (Legal Business Name): LISA M MANES-MANKINS M.S., CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/21/2007
Last Update Date: 06/18/2024
Certification Date: 06/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 ELFEN GLEN ST
VAN BUREN AR
72956-2222
US

IV. Provider business mailing address

10 ELFEN GLEN ST
VAN BUREN AR
72956-2222
US

V. Phone/Fax

Practice location:
  • Phone: 479-420-0817
  • Fax:
Mailing address:
  • Phone: 794-420-0817
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number2350
License Number StateAR
# 2
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number212
License Number StateAK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: