Healthcare Provider Details

I. General information

NPI: 1336279207
Provider Name (Legal Business Name): TANIA MANCZAREK MSW, LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/07/2007
Last Update Date: 10/07/2026
Certification Date: 10/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

54 GLEN HAVEN RDG
SOQUEL CA
95073-9430
US

IV. Provider business mailing address

54 GLEN HAVEN RDG
SOQUEL CA
95073-9430
US

V. Phone/Fax

Practice location:
  • Phone: 310-386-0614
  • Fax:
Mailing address:
  • Phone: 310-386-0614
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCS 22075
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: