Provider Demographics
NPI:1689769622
Name:MANCILLAS, PAUL JOSEPH (PHD)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:JOSEPH
Last Name:MANCILLAS
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:330 S. LA SERENA DR.
Mailing Address - Street 2:
Mailing Address - City:WEST COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91791
Mailing Address - Country:US
Mailing Address - Phone:626-339-1158
Mailing Address - Fax:626-331-8551
Practice Address - Street 1:100 S. CITRUS AVE
Practice Address - Street 2:STE 206
Practice Address - City:COVINA
Practice Address - State:CA
Practice Address - Zip Code:91723
Practice Address - Country:US
Practice Address - Phone:626-331-6999
Practice Address - Fax:626-331-8551
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY10364103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACP10364AMedicare ID - Type Unspecified