Healthcare Provider Details

I. General information

NPI: 1447752951
Provider Name (Legal Business Name): CHRIS SIXTO MANZANARES LADAC, LBSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: CHRIS SIXTO MANZANARES LADAC, LBSW

II. Dates (important events)

Enumeration Date: 03/01/2018
Last Update Date: 03/01/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2301 7TH ST
LAS VEGAS NM
87701-4966
US

IV. Provider business mailing address

2301 7TH ST
LAS VEGAS NM
87701-4966
US

V. Phone/Fax

Practice location:
  • Phone: 505-454-9611
  • Fax:
Mailing address:
  • Phone: 505-454-9611
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number005707
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: