Provider Demographics
NPI:1265817084
Name:MANZANO, JOSHUA REESE
Entity Type:Individual
Prefix:MR
First Name:JOSHUA
Middle Name:REESE
Last Name:MANZANO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5812 SUTCLIFFE CIR
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89110-3855
Mailing Address - Country:US
Mailing Address - Phone:702-518-7247
Mailing Address - Fax:
Practice Address - Street 1:5812 SUTCLIFFE CIR
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89110-3855
Practice Address - Country:US
Practice Address - Phone:702-518-7247
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-22
Last Update Date:2020-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV225400000X
R-DMT-2456225600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225600000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDance Therapist
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner