Provider Demographics
NPI:1477366995
Name:SUPREME, MAGUEDALENA MANOUCHEKA
Entity type:Individual
Prefix:
First Name:MAGUEDALENA
Middle Name:MANOUCHEKA
Last Name:SUPREME
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 MAIN ST APT 812
Mailing Address - Street 2:
Mailing Address - City:HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06106-1875
Mailing Address - Country:US
Mailing Address - Phone:305-399-9176
Mailing Address - Fax:
Practice Address - Street 1:250 MAIN ST APT 812
Practice Address - Street 2:
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06106-1875
Practice Address - Country:US
Practice Address - Phone:305-399-9176
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-29
Last Update Date:2025-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician