Provider Demographics
NPI:1497498257
Name:MANES, WENDY (BACB759842)
Entity Type:Individual
Prefix:
First Name:WENDY
Middle Name:
Last Name:MANES
Suffix:
Gender:F
Credentials:BACB759842
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12007 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:SEFFNER
Mailing Address - State:FL
Mailing Address - Zip Code:33584-5235
Mailing Address - Country:US
Mailing Address - Phone:971-284-8442
Mailing Address - Fax:
Practice Address - Street 1:12007 PARK AVE
Practice Address - Street 2:
Practice Address - City:SEFFNER
Practice Address - State:FL
Practice Address - Zip Code:33584-5235
Practice Address - Country:US
Practice Address - Phone:971-284-8442
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-19
Last Update Date:2022-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-22-201989106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician