Provider Demographics
NPI:1114043155
Name:MANES-MANKINS, LISA M (MS, CCC-SLP)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:M
Last Name:MANES-MANKINS
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 ELFEN GLEN ST
Mailing Address - Street 2:
Mailing Address - City:VAN BUREN
Mailing Address - State:AR
Mailing Address - Zip Code:72956-2222
Mailing Address - Country:US
Mailing Address - Phone:794-420-0817
Mailing Address - Fax:
Practice Address - Street 1:10 ELFEN GLEN ST
Practice Address - Street 2:
Practice Address - City:VAN BUREN
Practice Address - State:AR
Practice Address - Zip Code:72956-2222
Practice Address - Country:US
Practice Address - Phone:479-420-0817
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-21
Last Update Date:2024-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2350235Z00000X
AK212235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK40381Medicaid
AR156334721Medicaid