Provider Demographics
NPI:1720474042
Name:MANECKE, STEPHANIE
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:MANECKE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9900 SHELBYVILLE RD STE 8
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40223-2965
Mailing Address - Country:US
Mailing Address - Phone:502-777-8884
Mailing Address - Fax:
Practice Address - Street 1:9900 SHELBYVILLE RD STE 8
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40223-2965
Practice Address - Country:US
Practice Address - Phone:502-777-8884
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-14
Last Update Date:2022-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1-15-18570103K00000X
KY00218604103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100346270Medicaid