Healthcare Provider Details

I. General information

NPI: 1639920119
Provider Name (Legal Business Name): DWIGHT HANNIBAL MANLEY RBT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/01/2024
Last Update Date: 07/13/2026
Certification Date: 07/13/2026
Deactivation Date: 05/05/2026
Reactivation Date: 07/02/2026

III. Provider practice location address

275 UPPER RIVERDALE RD SW STE D
RIVERDALE GA
30274-2556
US

IV. Provider business mailing address

422 LEES LAKE RD
FAYETTEVILLE GA
30214-3106
US

V. Phone/Fax

Practice location:
  • Phone: 888-595-7159
  • Fax:
Mailing address:
  • Phone: 229-412-2081
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-26-541799
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: