Provider Demographics
NPI:1609383892
Name:MANCHESTER, MACI
Entity Type:Individual
Prefix:
First Name:MACI
Middle Name:
Last Name:MANCHESTER
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:PO BOX 151716
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78715-1716
Mailing Address - Country:US
Mailing Address - Phone:512-898-9044
Mailing Address - Fax:512-857-1423
Practice Address - Street 1:2301 BAGDAD RD STE 305
Practice Address - Street 2:
Practice Address - City:CEDAR PARK
Practice Address - State:TX
Practice Address - Zip Code:78613-6503
Practice Address - Country:US
Practice Address - Phone:512-898-9044
Practice Address - Fax:512-857-1423
Is Sole Proprietor?:No
Enumeration Date:2018-01-09
Last Update Date:2021-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX3944103K00000X
TX2719103K00000X
TX0-17-8230106E00000X
CA0-17-8230106E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst