Provider Demographics
NPI:1295374478
Name:MICHAEL MANCILLA LICSW
Entity Type:Organization
Organization Name:MICHAEL MANCILLA LICSW
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:THERAPIST/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:A
Authorized Official - Last Name:MANCILLA
Authorized Official - Suffix:
Authorized Official - Credentials:LICSW
Authorized Official - Phone:202-234-2299
Mailing Address - Street 1:437 NEW YORK AVE NW APT 211
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20001-4746
Mailing Address - Country:US
Mailing Address - Phone:202-234-2299
Mailing Address - Fax:
Practice Address - Street 1:1629 K ST NW STE 300
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20006-1631
Practice Address - Country:US
Practice Address - Phone:202-234-2299
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-01-05
Last Update Date:2020-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty