Provider Demographics
NPI:1649510405
Name:MANCILLAS, LAUREN MARIE
Entity type:Individual
Prefix:
First Name:LAUREN
Middle Name:MARIE
Last Name:MANCILLAS
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 1:8700 MONTANA AVE
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79925-1221
Mailing Address - Country:US
Mailing Address - Phone:915-771-8523
Mailing Address - Fax:915-771-8046
Practice Address - Street 1:8700 MONTANA AVE
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79925-1221
Practice Address - Country:US
Practice Address - Phone:915-771-8523
Practice Address - Fax:915-771-8046
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-15
Last Update Date:2018-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX374672355S0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX149984001Medicaid
TX207164901Medicaid
TX149984001Medicaid
TX207164901Medicaid