Provider Demographics
NPI:1629726575
Name:MANRIQUE, CAMILA
Entity Type:Individual
Prefix:
First Name:CAMILA
Middle Name:
Last Name:MANRIQUE
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 1:3046 CLOVERLY LN
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48108-3083
Mailing Address - Country:US
Mailing Address - Phone:954-826-8656
Mailing Address - Fax:
Practice Address - Street 1:1100 VICTORS WAY STE 10
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48108-5220
Practice Address - Country:US
Practice Address - Phone:734-973-6779
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-10
Last Update Date:2023-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6451023115101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health