Provider Demographics
NPI:1497472096
Name:MANCILLA, JOANNA
Entity Type:Individual
Prefix:
First Name:JOANNA
Middle Name:
Last Name:MANCILLA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12450 VAN NUYS BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:PACOIMA
Mailing Address - State:CA
Mailing Address - Zip Code:91331-1393
Mailing Address - Country:US
Mailing Address - Phone:818-896-1161
Mailing Address - Fax:818-896-5069
Practice Address - Street 1:12450 VAN NUYS BLVD STE 200
Practice Address - Street 2:
Practice Address - City:PACOIMA
Practice Address - State:CA
Practice Address - Zip Code:91331-1393
Practice Address - Country:US
Practice Address - Phone:818-896-1161
Practice Address - Fax:818-896-5069
Is Sole Proprietor?:No
Enumeration Date:2022-10-24
Last Update Date:2023-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAASW113512101YM0800X, 1041C0700X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA6758Medicaid
CA7068Medicaid
CA1954Medicaid
CA7420Medicaid