Basic Information
Provider Information | |||||||||
NPI: | 1831793280 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MANINGAS | ||||||||
FirstName: | MAXIM | ||||||||
MiddleName: | RAYMUNDO | ||||||||
NamePrefix: | MR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | ACSW | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | MANINGAS | ||||||||
OtherFirstName: | MAXIM | ||||||||
OtherMiddleName: | RAYMUNDO | ||||||||
OtherNamePrefix: | MR. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | ACSW | ||||||||
OtherLastNameType: | 2 | ||||||||
Mailing Information | |||||||||
Address1: | 3853 ROSECRANS ST | ||||||||
Address2: |   | ||||||||
City: | SAN DIEGO | ||||||||
State: | CA | ||||||||
PostalCode: | 921103115 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6196928257 | ||||||||
FaxNumber: | 6195424060 | ||||||||
Practice Location | |||||||||
Address1: | 3853 ROSECRANS ST | ||||||||
Address2: |   | ||||||||
City: | SAN DIEGO | ||||||||
State: | CA | ||||||||
PostalCode: | 921103115 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6196928257 | ||||||||
FaxNumber: | 6195424060 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/25/2020 | ||||||||
LastUpdateDate: | 11/25/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 11/25/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | ASW96885 | CA | Y |   | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
ID | Type | State | Issuer | Description | ASW96885 | 05 | CA |   | MEDICAID |