Healthcare Provider Details

I. General information

NPI: 1821593237
Provider Name (Legal Business Name): EVAN MCMANAMY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/27/2018
Last Update Date: 08/26/2022
Certification Date: 08/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

433 BROADWAY
PROVIDENCE RI
02909-1624
US

IV. Provider business mailing address

433 BROADWAY
PROVIDENCE RI
02909-1624
US

V. Phone/Fax

Practice location:
  • Phone: 401-680-0334
  • Fax:
Mailing address:
  • Phone: 401-680-0334
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberCSW02741
License Number StateRI
# 2
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMA60845227
License Number StateWA
# 3
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMT02510
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: