Provider Demographics
NPI:1750436010
Name:MANZANO, MARY THERESA (MS CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:MARY
Middle Name:THERESA
Last Name:MANZANO
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 242
Mailing Address - Street 2:
Mailing Address - City:LAKESIDE
Mailing Address - State:OR
Mailing Address - Zip Code:97449-0242
Mailing Address - Country:US
Mailing Address - Phone:928-243-3245
Mailing Address - Fax:
Practice Address - Street 1:1604 COLUMBINE VILLAGE DR
Practice Address - Street 2:
Practice Address - City:WOODLAND PARK
Practice Address - State:CO
Practice Address - Zip Code:80863-8339
Practice Address - Country:US
Practice Address - Phone:737-787-7367
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-24
Last Update Date:2023-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR016183235Z00000X
WALL61410586235Z00000X
CO5589235Z00000X
AZSLP4815235Z00000X
CA13710235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ083937Medicaid