MEDICARE: MR. DENNIS MANESS PH.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor	2457 BCN	CA
2	101YM0800X	Mental Health Counselor	2457 BCN	CA
3	103G00000X	Clinical Neuropsychologist	2457 BCN	CA
4	103K00000X	Behavior Analyst	2457 BCN	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2457 BCN	OTHER	CA	BOARD CERTIFIED NEUROTHERAPIST

General Provider Information

NPI Number	:	1336583764
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. DENNIS MANESS PH.D.

Provider Business Mailing Address
First Line	:	3978 SORRENTO VALLEY BLVD
Second Line	:	#310
City	:	SAN DIEGO
State	:	CA
Zip	:	92121-1436
Country	:	US
Telephone Number	:	858-222-9138
Fax Number	:	858-385-0222

Provider Business Practice Location Address
First Line	:	3978 SORRENTO VALLEY BLVD
Second Line	:	#310
City	:	SAN DIEGO
State	:	CA
Zip	:	92121-1436
Country	:	US
Telephone Number	:	858-222-9138
Fax Number	:	858-385-0222

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/29/2013
Last Update Date	:	04/29/2013

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Directions to “ MR. DENNIS MANESS PH.D.” Practice Location

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