Provider Demographics
NPI:1649459835
Name:MANIVANH, THEB (LCSW)
Entity type:Individual
Prefix:MR
First Name:THEB
Middle Name:
Last Name:MANIVANH
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1950
Mailing Address - Street 2:
Mailing Address - City:LAKEPORT
Mailing Address - State:CA
Mailing Address - Zip Code:95453-1950
Mailing Address - Country:US
Mailing Address - Phone:707-263-8382
Mailing Address - Fax:707-263-0329
Practice Address - Street 1:925 BEVINS CT
Practice Address - Street 2:
Practice Address - City:LAKEPORT
Practice Address - State:CA
Practice Address - Zip Code:95453-9754
Practice Address - Country:US
Practice Address - Phone:707-263-8382
Practice Address - Fax:707-263-0329
Is Sole Proprietor?:No
Enumeration Date:2007-10-24
Last Update Date:2025-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA282511041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA28251OtherLCSW