Healthcare Provider Details

I. General information

NPI: 1750566337
Provider Name (Legal Business Name): CHRISTINE MACMANUS SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/02/2008
Last Update Date: 10/17/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

176 MAIN ST KENNEDY DONOVAN CENTER
SOUTHBRIDGE MA
01550-2561
US

IV. Provider business mailing address

176 MAIN ST KENNEDY DONOVAN CENTER
SOUTHBRIDGE MA
01550-2561
US

V. Phone/Fax

Practice location:
  • Phone: 508-765-0292
  • Fax: 508-765-0294
Mailing address:
  • Phone: 508-765-0292
  • Fax: 508-765-0294

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number5171
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number2133
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: