Provider Demographics
NPI:1811607633
Name:DAZA, MANUEL ALFONSO (MHA)
Entity type:Individual
Prefix:
First Name:MANUEL
Middle Name:ALFONSO
Last Name:DAZA
Suffix:
Gender:M
Credentials:MHA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 MANSFIELD AVE APT B101
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:02048-1995
Mailing Address - Country:US
Mailing Address - Phone:520-612-9551
Mailing Address - Fax:
Practice Address - Street 1:134 THURBERS AVE STE 212
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02905-4721
Practice Address - Country:US
Practice Address - Phone:401-383-5051
Practice Address - Fax:401-432-7082
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-02
Last Update Date:2022-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty