Provider Demographics
NPI:1689415283
Name:MANIBUSAN, LEIA
Entity type:Individual
Prefix:
First Name:LEIA
Middle Name:
Last Name:MANIBUSAN
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 1:1708 MCDANIEL ST
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:VA
Mailing Address - Zip Code:23704-1731
Mailing Address - Country:US
Mailing Address - Phone:757-639-5850
Mailing Address - Fax:757-485-1989
Practice Address - Street 1:732 EDEN WAY N STE E563
Practice Address - Street 2:
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23320-2798
Practice Address - Country:US
Practice Address - Phone:540-915-2114
Practice Address - Fax:757-485-1989
Is Sole Proprietor?:No
Enumeration Date:2024-06-05
Last Update Date:2024-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician