Provider Demographics
NPI:1104951136
Name:MANKOFF, ROBERT GRENFELL (PHD)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:GRENFELL
Last Name:MANKOFF
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4029 BALSAM DR
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27612-3605
Mailing Address - Country:US
Mailing Address - Phone:919-781-5199
Mailing Address - Fax:
Practice Address - Street 1:4000 BLUE RIDGE RD
Practice Address - Street 2:SUITE 200
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27612-4650
Practice Address - Country:US
Practice Address - Phone:919-782-4981
Practice Address - Fax:919-782-2474
Is Sole Proprietor?:No
Enumeration Date:2007-02-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1963103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6000666Medicaid