Provider Demographics
NPI:1184062770
Name:TRAUB, MANYA ROXANE (LAC)
Entity type:Individual
Prefix:
First Name:MANYA
Middle Name:ROXANE
Last Name:TRAUB
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:263 S WILTON PL
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90004-4911
Mailing Address - Country:US
Mailing Address - Phone:323-939-0738
Mailing Address - Fax:
Practice Address - Street 1:263 S WILTON PL
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90004-4911
Practice Address - Country:US
Practice Address - Phone:323-939-0738
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-05
Last Update Date:2013-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC15257171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA4629194176OtherIRS