Healthcare Provider Details

I. General information

NPI: 1669700720
Provider Name (Legal Business Name): LUIS MANZO PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/01/2009
Last Update Date: 12/01/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 E 40TH ST SUITE 406
NEW YORK NY
10016-1801
US

IV. Provider business mailing address

892 UNION ST
BROOKLYN NY
11215-1602
US

V. Phone/Fax

Practice location:
  • Phone: 347-534-8798
  • Fax:
Mailing address:
  • Phone: 347-534-8798
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number016307
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code103TA0400X
TaxonomyAddiction (Substance Use Disorder) Psychologist
License Number016307
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number016307
License Number StateNY
# 4
Primary TaxonomyN
Taxonomy Code103TE1100X
TaxonomyExercise & Sports Psychologist
License Number016307
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: