Provider Demographics
NPI:1356606339
Name:MANOLAKOS, JOHN JAMES
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:JAMES
Last Name:MANOLAKOS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6908 GOTHIC MARIGOLD ST
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89149-3013
Mailing Address - Country:US
Mailing Address - Phone:702-541-1873
Mailing Address - Fax:
Practice Address - Street 1:5130 S PECOS RD
Practice Address - Street 2:APT/SUITE 2B
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89120-1248
Practice Address - Country:US
Practice Address - Phone:702-900-7397
Practice Address - Fax:888-753-3302
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-06
Last Update Date:2012-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV900837799Medicaid