1750625372 NPI number — MICHELLE L MANNIA PSYD

Table of content: MICHELLE L MANNIA PSYD (NPI 1750625372)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750625372 NPI number — MICHELLE L MANNIA PSYD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MANNIA
Provider First Name:
MICHELLE
Provider Middle Name:
L
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PSYD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
LESLIE
Provider Other First Name:
MICHELLE
Provider Other Middle Name:
L
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PSYD
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1750625372
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/17/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4507 EAGLE CREEK PKWY
Provider Second Line Business Mailing Address:
UNIT 310
Provider Business Mailing Address City Name:
INDIANAPOLIS
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46254-4374
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
574-276-9556
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6640 INTECH BLVD
Provider Second Line Business Practice Location Address:
STE 195
Provider Business Practice Location Address City Name:
INDIANAPOLIS
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46278-2011
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
317-295-0608
Provider Business Practice Location Address Fax Number:
317-295-0622
Provider Enumeration Date:
11/20/2012

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X , with the licence number:  39002420A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103TC0700X , with the licence number: 20042755A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 201228760 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com