MEDICARE: NATHALY MANIVANH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106E00000X	Assistant Behavior Analyst	0-17-8384	CA

General Provider Information

NPI Number	:	1568979771
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NATHALY MANIVANH

Provider Business Mailing Address
First Line	:	PO BOX 5157
Second Line	:
City	:	MODESTO
State	:	CA
Zip	:	95352-5157
Country	:	US
Telephone Number	:	209-572-2589
Fax Number	:	209-572-1461

Provider Business Practice Location Address
First Line	:	5601 ARNOLD RD FL 100
Second Line	:
City	:	DUBLIN
State	:	CA
Zip	:	94568-7726
Country	:	US
Telephone Number	:	209-572-2589
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/09/2018
Last Update Date	:	01/09/2018

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Directions to “ NATHALY MANIVANH ” Practice Location

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