Provider Demographics
NPI:1780779504
Name:LUA, MANUEL (MFT)
Entity type:Individual
Prefix:
First Name:MANUEL
Middle Name:
Last Name:LUA
Suffix:
Gender:M
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2495 W MARCH LN
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95207-8251
Mailing Address - Country:US
Mailing Address - Phone:209-320-7600
Mailing Address - Fax:
Practice Address - Street 1:2495 W MARCH LN STE 125
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95207-8224
Practice Address - Country:US
Practice Address - Phone:209-320-7615
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2016-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA771119106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA106H00000XOtherTAXONOMY