Provider Demographics
NPI:1528698057
Name:MANCILLAS, ANYA KATZINA
Entity type:Individual
Prefix:MISS
First Name:ANYA
Middle Name:KATZINA
Last Name:MANCILLAS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:594 IVY CT
Mailing Address - Street 2:
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91911-2503
Mailing Address - Country:US
Mailing Address - Phone:619-410-5628
Mailing Address - Fax:
Practice Address - Street 1:1809 NATIONAL AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92113-2113
Practice Address - Country:US
Practice Address - Phone:619-515-2515
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-23
Last Update Date:2020-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA14305235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist