Healthcare Provider Details

I. General information

NPI: 1225867401
Provider Name (Legal Business Name): COLLEEN MELINDA MANUS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/29/2024
Last Update Date: 07/29/2024
Certification Date: 07/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4688 ONTARIO MILLS PKWY
ONTARIO CA
91764-5104
US

IV. Provider business mailing address

1473 W 15TH ST
UPLAND CA
91786-2147
US

V. Phone/Fax

Practice location:
  • Phone: 909-476-5747
  • Fax:
Mailing address:
  • Phone: 909-739-4582
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106E00000X
TaxonomyAssistant Behavior Analyst
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: