Provider Demographics
NPI:1871037739
Name:FAEZ, MANI
Entity Type:Individual
Prefix:
First Name:MANI
Middle Name:
Last Name:FAEZ
Suffix:
Gender:M
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 11390
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:WY
Mailing Address - Zip Code:83002-1390
Mailing Address - Country:US
Mailing Address - Phone:307-733-3908
Mailing Address - Fax:307-734-0017
Practice Address - Street 1:610 W BROADWAY AVE STE L-1
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:WY
Practice Address - Zip Code:83001-8213
Practice Address - Country:US
Practice Address - Phone:307-733-3908
Practice Address - Fax:307-734-0017
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-12
Last Update Date:2022-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA89498106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist