Provider Demographics
NPI:1699461574
Name:VICENTE, MANUEL SANTIAGO (LPC-A)
Entity type:Individual
Prefix:
First Name:MANUEL
Middle Name:SANTIAGO
Last Name:VICENTE
Suffix:
Gender:M
Credentials:LPC-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2410 JEFFERSON POINT DR APT 532
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76006-4236
Mailing Address - Country:US
Mailing Address - Phone:813-317-6396
Mailing Address - Fax:
Practice Address - Street 1:2410 JEFFERSON POINT DR APT 532
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76006-4236
Practice Address - Country:US
Practice Address - Phone:813-317-6396
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-13
Last Update Date:2023-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX90335101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health