Provider Demographics
NPI:1598412389
Name:MANKO, MASHA
Entity Type:Individual
Prefix:
First Name:MASHA
Middle Name:
Last Name:MANKO
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 1:30 CATANIA
Mailing Address - Street 2:
Mailing Address - City:MISSION VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92692-5126
Mailing Address - Country:US
Mailing Address - Phone:949-338-7811
Mailing Address - Fax:
Practice Address - Street 1:13200 CROSSROADS PKWY N
Practice Address - Street 2:
Practice Address - City:CITY OF INDUSTRY
Practice Address - State:CA
Practice Address - Zip Code:91746-3459
Practice Address - Country:US
Practice Address - Phone:562-821-9603
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-02
Last Update Date:2022-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA6727Medicaid