Provider Demographics
NPI:1376100214
Name:MANEZ TABAREZ, RICARDO (BA)
Entity type:Individual
Prefix:
First Name:RICARDO
Middle Name:
Last Name:MANEZ TABAREZ
Suffix:
Gender:M
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12141 BROOKHURST ST STE 101
Mailing Address - Street 2:
Mailing Address - City:GARDEN GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:92840-2865
Mailing Address - Country:US
Mailing Address - Phone:714-392-1514
Mailing Address - Fax:
Practice Address - Street 1:12141 BROOKHURST ST STE 100
Practice Address - Street 2:
Practice Address - City:GARDEN GROVE
Practice Address - State:CA
Practice Address - Zip Code:92840-2865
Practice Address - Country:US
Practice Address - Phone:714-921-4087
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-27
Last Update Date:2024-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101YM0800X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAF2303792OtherCA GOVT