Provider Demographics
NPI:1447357124
Name:MANRIQUEZ, DEBRA ANN (MFT)
Entity type:Individual
Prefix:MS
First Name:DEBRA
Middle Name:ANN
Last Name:MANRIQUEZ
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1430 E COOLEY DR STE 111
Mailing Address - Street 2:
Mailing Address - City:COLTON
Mailing Address - State:CA
Mailing Address - Zip Code:92324-3944
Mailing Address - Country:US
Mailing Address - Phone:909-825-5128
Mailing Address - Fax:909-825-8568
Practice Address - Street 1:1430 E COOLEY DR STE 111
Practice Address - Street 2:
Practice Address - City:COLTON
Practice Address - State:CA
Practice Address - Zip Code:92324-3944
Practice Address - Country:US
Practice Address - Phone:909-825-5128
Practice Address - Fax:909-825-8568
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC 39210106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist