Provider Demographics
NPI:1881183523
Name:MANBRAIN INCORPORATED
Entity Type:Organization
Organization Name:MANBRAIN INCORPORATED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:WURTH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:210-920-1572
Mailing Address - Street 1:8311 SETTING MOON
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78255-3308
Mailing Address - Country:US
Mailing Address - Phone:210-620-7700
Mailing Address - Fax:
Practice Address - Street 1:16607 BLANCO RD STE 904
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78232-1942
Practice Address - Country:US
Practice Address - Phone:210-920-1572
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-08
Last Update Date:2019-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX12744101YA0400X
TX73182101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1801284781Medicaid