Provider Demographics
NPI:1316703028
Name:MANCILLAS, MONIQUE (MS, CCC-SLP)
Entity type:Individual
Prefix:
First Name:MONIQUE
Middle Name:
Last Name:MANCILLAS
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2160 W ADAMS BLVD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90018-2039
Mailing Address - Country:US
Mailing Address - Phone:213-863-9963
Mailing Address - Fax:
Practice Address - Street 1:2160 W ADAMS BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90018-2039
Practice Address - Country:US
Practice Address - Phone:213-863-9963
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-21
Last Update Date:2024-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA35736235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist