Provider Demographics
NPI:1013903012
Name:CORDERO, MANUEL ROBERT (MED,LPC-S)
Entity Type:Individual
Prefix:
First Name:MANUEL
Middle Name:ROBERT
Last Name:CORDERO
Suffix:
Gender:M
Credentials:MED,LPC-S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14623 TRIPLE CROWN LN
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78248-2506
Mailing Address - Country:US
Mailing Address - Phone:210-422-8702
Mailing Address - Fax:210-492-0423
Practice Address - Street 1:8401 DATAPOINT DR STE 301
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-5904
Practice Address - Country:US
Practice Address - Phone:210-354-1186
Practice Address - Fax:210-354-1187
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-25
Last Update Date:2023-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX11726101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX026505001Medicaid