Provider Demographics
NPI:1255632709
Name:MANZO, GREGORY (MSBCBA, LBA)
Entity type:Individual
Prefix:MR
First Name:GREGORY
Middle Name:
Last Name:MANZO
Suffix:
Gender:M
Credentials:MSBCBA, LBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:91-1159 KAMAKANA ST APT 120
Mailing Address - Street 2:
Mailing Address - City:EWA BEACH
Mailing Address - State:HI
Mailing Address - Zip Code:96706-2023
Mailing Address - Country:US
Mailing Address - Phone:808-721-8386
Mailing Address - Fax:619-374-7134
Practice Address - Street 1:91-1159 KAMAKANA ST APT 120
Practice Address - Street 2:
Practice Address - City:EWA BEACH
Practice Address - State:HI
Practice Address - Zip Code:96706-2023
Practice Address - Country:US
Practice Address - Phone:808-721-8386
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-11-14
Last Update Date:2022-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI1-09-6693103K00000X
HIBA-90103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst