Healthcare Provider Details

I. General information

NPI: 1487541934
Provider Name (Legal Business Name): EMMA MANKUS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/18/2025
Last Update Date: 12/09/2025
Certification Date: 12/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 VISTA CENTRE DR
FOREST VA
24551-2775
US

IV. Provider business mailing address

3715 CAMPBELL AVE
LYNCHBURG VA
24501-4503
US

V. Phone/Fax

Practice location:
  • Phone: 804-391-4026
  • Fax:
Mailing address:
  • Phone: 804-391-4026
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number0701015687
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: