Healthcare Provider Details

I. General information

NPI: 1396222717
Provider Name (Legal Business Name): TIALA DION MANNING
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/27/2018
Last Update Date: 08/26/2026
Certification Date: 08/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4353 PARK BLVD APT 635
SAN DIEGO CA
92103-2578
US

IV. Provider business mailing address

4353 PARK BLVD APT 635
SAN DIEGO CA
92103-2578
US

V. Phone/Fax

Practice location:
  • Phone: 619-365-6335
  • Fax:
Mailing address:
  • Phone: 619-356-6335
  • Fax: 858-987-8653

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number42142
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: