Provider Demographics
NPI:1447619523
Name:ATHANS, MANNY
Entity Type:Individual
Prefix:MR
First Name:MANNY
Middle Name:
Last Name:ATHANS
Suffix:
Gender:M
Credentials:
Other - Prefix:MR
Other - First Name:MANNY
Other - Middle Name:
Other - Last Name:ATHANS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LISAC
Mailing Address - Street 1:PO BOX 38
Mailing Address - Street 2:
Mailing Address - City:SACATON
Mailing Address - State:AZ
Mailing Address - Zip Code:85147
Mailing Address - Country:US
Mailing Address - Phone:602-528-1200
Mailing Address - Fax:602-528-1374
Practice Address - Street 1:483 W. SEED FARM RD.
Practice Address - Street 2:
Practice Address - City:SACATON
Practice Address - State:AZ
Practice Address - Zip Code:85147
Practice Address - Country:US
Practice Address - Phone:602-528-1200
Practice Address - Fax:602-528-1374
Is Sole Proprietor?:No
Enumeration Date:2016-02-17
Last Update Date:2016-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ10524101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ10524OtherBH LICENSE