MEDICARE: ALISSA RAYLEE MANCILLA

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	103TA0400X	Addiction (Substance Use Disorder) Psychologist

General Provider Information

NPI Number	:	1922930064
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ALISSA RAYLEE MANCILLA

Provider Business Mailing Address
First Line	:	3636 N 1ST ST STE 135
Second Line	:
City	:	FRESNO
State	:	CA
Zip	:	93726-6818
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3636 N 1ST ST STE 135
Second Line	:
City	:	FRESNO
State	:	CA
Zip	:	93726-6818
Country	:	US
Telephone Number	:	559-940-1629
Fax Number	:

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

Provider Enumeration Date	:	06/02/2026
Last Update Date	:	06/02/2026

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Directions to “ ALISSA RAYLEE MANCILLA ” Practice Location

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