Provider Demographics
NPI:1669216065
Name:MANZO, CODY
Entity type:Individual
Prefix:
First Name:CODY
Middle Name:
Last Name:MANZO
Suffix:
Gender:U
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12001 DR. M.L.K JR ST N
Mailing Address - Street 2:
Mailing Address - City:ST. PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33716
Mailing Address - Country:US
Mailing Address - Phone:760-577-8452
Mailing Address - Fax:
Practice Address - Street 1:5250 87TH TER N
Practice Address - Street 2:
Practice Address - City:PINELLAS PARK
Practice Address - State:FL
Practice Address - Zip Code:33782-5136
Practice Address - Country:US
Practice Address - Phone:727-666-3217
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-20
Last Update Date:2024-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-23-285902106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician