Provider Demographics
NPI:1194363424
Name:BOYKO, MANESSA
Entity type:Individual
Prefix:
First Name:MANESSA
Middle Name:
Last Name:BOYKO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4510 PERALTA BLVD STE 1
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94536-5755
Mailing Address - Country:US
Mailing Address - Phone:510-713-3202
Mailing Address - Fax:510-713-0684
Practice Address - Street 1:37437 GLENMOOR DR
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:CA
Practice Address - Zip Code:94536-5731
Practice Address - Country:US
Practice Address - Phone:510-713-3200
Practice Address - Fax:510-713-0684
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-17
Last Update Date:2019-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)