Provider Demographics
NPI:1548756190
Name:MANCILLA, SELENE
Entity Type:Individual
Prefix:
First Name:SELENE
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 1:3805 DAVID DR
Mailing Address - Street 2:
Mailing Address - City:NORTH HIGHLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:95660-4512
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3333 VACA VALLEY PKWY STE 900
Practice Address - Street 2:
Practice Address - City:VACAVILLE
Practice Address - State:CA
Practice Address - Zip Code:95688-9419
Practice Address - Country:US
Practice Address - Phone:707-317-5584
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-06
Last Update Date:2018-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst