Provider Demographics
NPI:1548298755
Name:MANULKIN, ALISA J (PHD)
Entity type:Individual
Prefix:DR
First Name:ALISA
Middle Name:J
Last Name:MANULKIN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2012 CHARRWOOD WAY
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30062-8501
Mailing Address - Country:US
Mailing Address - Phone:954-655-7967
Mailing Address - Fax:770-671-0476
Practice Address - Street 1:2012 CHARRWOOD WAY
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30062-8501
Practice Address - Country:US
Practice Address - Phone:954-655-7967
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2022-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY5370103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL7635907-00Medicaid
FL54627Medicare ID - Type Unspecified