Provider Demographics
NPI:1972957827
Name:ATHWAL, MANJUNDER
Entity type:Individual
Prefix:
First Name:MANJUNDER
Middle Name:
Last Name:ATHWAL
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 1:1118 CYPRESS HILL LN
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95206-6245
Mailing Address - Country:US
Mailing Address - Phone:209-986-0946
Mailing Address - Fax:209-910-0531
Practice Address - Street 1:1118 CYPRESS HILL LN
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95206-6245
Practice Address - Country:US
Practice Address - Phone:209-986-0946
Practice Address - Fax:209-910-0531
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-18
Last Update Date:2016-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)