Healthcare Provider Details

I. General information

NPI: 1902554793
Provider Name (Legal Business Name): GLORIA DANYALE MANICA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/11/2022
Last Update Date: 10/08/2026
Certification Date: 10/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 HERITAGE DR STE 520
SOUTHGATE MI
48195-3051
US

IV. Provider business mailing address

1126 MILL ST
LINCOLN PARK MI
48146-2442
US

V. Phone/Fax

Practice location:
  • Phone: 734-430-9211
  • Fax:
Mailing address:
  • Phone: 734-430-9211
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number6401226530
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: