Provider Demographics
NPI:1346530631
Name:DAN L. MANZANARES, PSYD, PC
Entity Type:Organization
Organization Name:DAN L. MANZANARES, PSYD, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:DAN
Authorized Official - Middle Name:L
Authorized Official - Last Name:MANZANARES
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:303-757-3352
Mailing Address - Street 1:4770 E ILIFF AVE
Mailing Address - Street 2:102
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80222-6061
Mailing Address - Country:US
Mailing Address - Phone:303-757-3352
Mailing Address - Fax:303-757-7994
Practice Address - Street 1:4770 E ILIFF AVE
Practice Address - Street 2:102
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80222-6061
Practice Address - Country:US
Practice Address - Phone:303-757-3352
Practice Address - Fax:303-757-7994
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-08
Last Update Date:2011-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1070261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO07106636Medicaid
CO07106636Medicaid