Provider Demographics
NPI:1396598827
Name:CRISTOBAL MENESES, ENRIQUE
Entity type:Individual
Prefix:
First Name:ENRIQUE
Middle Name:
Last Name:CRISTOBAL MENESES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13500 FOOTHILL BLVD APT 201B
Mailing Address - Street 2:
Mailing Address - City:SYLMAR
Mailing Address - State:CA
Mailing Address - Zip Code:91342-4455
Mailing Address - Country:US
Mailing Address - Phone:747-241-7520
Mailing Address - Fax:
Practice Address - Street 1:762 GRISWOLD AVE
Practice Address - Street 2:
Practice Address - City:SAN FERNANDO
Practice Address - State:CA
Practice Address - Zip Code:91340-2105
Practice Address - Country:US
Practice Address - Phone:747-500-9405
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-05
Last Update Date:2024-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA7286101YA0400X, 171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)