Provider Demographics
NPI:1013922590
Name:MANZANARES, DAN L (PSYD)
Entity Type:Individual
Prefix:DR
First Name:DAN
Middle Name:L
Last Name:MANZANARES
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4770 E ILIFF AVE
Mailing Address - Street 2:#102
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80222-6061
Mailing Address - Country:US
Mailing Address - Phone:303-757-3352
Mailing Address - Fax:303-757-7994
Practice Address - Street 1:4770 E ILIFF AVE
Practice Address - Street 2:#102
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80222-6061
Practice Address - Country:US
Practice Address - Phone:303-757-3352
Practice Address - Fax:303-757-7994
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1070103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO07106636Medicaid
CO89116Medicare ID - Type Unspecified
CO89116Medicare UPIN