Healthcare Provider Details

I. General information

NPI: 1023112166
Provider Name (Legal Business Name): MICHAEL JOHN MANISCALCO MA, LLPC, CACLL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/11/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 STODDARD RD.
MEMPHIS MI
48041-1038
US

IV. Provider business mailing address

112 PLEASANT ST
ROMEO MI
48065-5141
US

V. Phone/Fax

Practice location:
  • Phone: 810-392-2167
  • Fax:
Mailing address:
  • Phone: 810-392-2167
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number6401009720
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: