Provider Demographics
NPI:1679799977
Name:MANIILAQ ASSOCIATION
Entity type:Organization
Organization Name:MANIILAQ ASSOCIATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:TREATMENT SERVICES SUPERVISOR
Authorized Official - Prefix:MS
Authorized Official - First Name:SHERRY
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:KULUKHON
Authorized Official - Suffix:
Authorized Official - Credentials:CCDCI
Authorized Official - Phone:907-442-7648
Mailing Address - Street 1:435 SECOND STREET TED STEVENS WAY
Mailing Address - Street 2:PO BOX 256
Mailing Address - City:KOTZEBUE
Mailing Address - State:AK
Mailing Address - Zip Code:99752-0256
Mailing Address - Country:US
Mailing Address - Phone:907-442-7648
Mailing Address - Fax:907-442-7821
Practice Address - Street 1:435 SECOND STREET TED STEVENS WAY
Practice Address - Street 2:
Practice Address - City:KOTZEBUE
Practice Address - State:AK
Practice Address - Zip Code:99752-0256
Practice Address - Country:US
Practice Address - Phone:907-442-7648
Practice Address - Fax:907-442-7821
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MANIILAQ ASSOCIATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-04-17
Last Update Date:2008-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK3059101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKMHO 212Medicaid