Healthcare Provider Details

I. General information

NPI: 1346288917
Provider Name (Legal Business Name): MANUEL MICHAEL CHAKNIS PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/03/2006
Last Update Date: 10/04/2023
Certification Date: 10/04/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2776 CLEVELAND AVE STE 602
FORT MYERS FL
33901-5864
US

IV. Provider business mailing address

PO BOX 2147
FORT MYERS FL
33902-2147
US

V. Phone/Fax

Practice location:
  • Phone: 239-343-1614
  • Fax: 239-343-3144
Mailing address:
  • Phone: 239-343-3900
  • Fax: 239-343-3144

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number0810003658
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPY0003426
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: