Provider Demographics
NPI:1376563916
Name:MANJARRES, RODRIGO (MA)
Entity Type:Individual
Prefix:
First Name:RODRIGO
Middle Name:
Last Name:MANJARRES
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:135 N GREENLEAF ST
Mailing Address - Street 2:SUITE 201
Mailing Address - City:GURNEE
Mailing Address - State:IL
Mailing Address - Zip Code:60031-3393
Mailing Address - Country:US
Mailing Address - Phone:847-360-8860
Mailing Address - Fax:847-360-8864
Practice Address - Street 1:3012 GRAND AVE
Practice Address - Street 2:
Practice Address - City:WAUKEGAN
Practice Address - State:IL
Practice Address - Zip Code:60085-2321
Practice Address - Country:US
Practice Address - Phone:847-546-0080
Practice Address - Fax:847-546-0083
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2007-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL5176101YA0400X
IL101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL8008517498OtherBLUECROSS BLUESHIELD