Provider Demographics
NPI:1790024446
Name:GARCIA AMAYA, MANUELA DEL MAR
Entity Type:Individual
Prefix:
First Name:MANUELA
Middle Name:DEL MAR
Last Name:GARCIA AMAYA
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 1:449 E PROVIDENCIA AVE
Mailing Address - Street 2:APT H
Mailing Address - City:BURBANK
Mailing Address - State:CA
Mailing Address - Zip Code:91501-2497
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:449 E PROVIDENCIA AVE
Practice Address - Street 2:APT H
Practice Address - City:BURBANK
Practice Address - State:CA
Practice Address - Zip Code:91501-2497
Practice Address - Country:US
Practice Address - Phone:818-679-8722
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-31
Last Update Date:2013-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAD8854276103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAJQC94920925EMedicaid