Healthcare Provider Details

I. General information

NPI: 1134957129
Provider Name (Legal Business Name): CLARISSA YVONNE MANKIN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/23/2024
Last Update Date: 04/29/2026
Certification Date: 04/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

228 N BARRON ST
EATON OH
45320-1704
US

IV. Provider business mailing address

224 MARILEE DR
NEW LEBANON OH
45345-1449
US

V. Phone/Fax

Practice location:
  • Phone: 937-456-7694
  • Fax:
Mailing address:
  • Phone: 937-732-1930
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code405300000X
TaxonomyPrevention Professional
License NumberRA164223
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number195797
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: