Provider Demographics
NPI:1619269677
Name:MANZANARES, RAEVIN MARIE
Entity Type:Individual
Prefix:MS
First Name:RAEVIN
Middle Name:MARIE
Last Name:MANZANARES
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 1:4121 DALE RD APT 42
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95356-8602
Mailing Address - Country:US
Mailing Address - Phone:209-499-5480
Mailing Address - Fax:
Practice Address - Street 1:508 MENDOCINO CT
Practice Address - Street 2:
Practice Address - City:ATWATER
Practice Address - State:CA
Practice Address - Zip Code:95301-4230
Practice Address - Country:US
Practice Address - Phone:209-357-5200
Practice Address - Fax:209-357-5279
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-10
Last Update Date:2011-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)