Provider Demographics
NPI:1588710222
Name:MANRIQUE, MANUEL ALEXANDER (PHD, LP)
Entity type:Individual
Prefix:DR
First Name:MANUEL
Middle Name:ALEXANDER
Last Name:MANRIQUE
Suffix:
Gender:M
Credentials:PHD, LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22967 OUTER DR
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48124-4248
Mailing Address - Country:US
Mailing Address - Phone:313-561-9064
Mailing Address - Fax:313-563-4480
Practice Address - Street 1:22967 OUTER DR
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48124-4248
Practice Address - Country:US
Practice Address - Phone:313-561-9064
Practice Address - Fax:313-563-4480
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-26
Last Update Date:2024-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301008353103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5552704OtherAETNA
MADR822439OtherMCDR
MI680H248190OtherBLUE CROSS BLUE SHIELD
MI680H248190OtherPPOM
MI680H248190OtherMCTWF
MI070564OtherVALUE OPTIONS M-CARE
MI070564OtherBCN
MI680H248190OtherMCTWF