Healthcare Provider Details

I. General information

NPI: 1871037739
Provider Name (Legal Business Name): MANI FAEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/12/2016
Last Update Date: 06/30/2022
Certification Date: 06/30/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

610 W BROADWAY AVE STE L-1
JACKSON WY
83001-8213
US

IV. Provider business mailing address

PO BOX 11390
JACKSON WY
83002-1390
US

V. Phone/Fax

Practice location:
  • Phone: 307-733-3908
  • Fax: 307-734-0017
Mailing address:
  • Phone: 307-733-3908
  • Fax: 307-734-0017

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number89498
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: