Provider Demographics
NPI:1356907208
Name:MANNI, MARY
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:MANNI
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 1:50920 VAN DYKE AVE
Mailing Address - Street 2:
Mailing Address - City:SHELBY TWP
Mailing Address - State:MI
Mailing Address - Zip Code:48317-1367
Mailing Address - Country:US
Mailing Address - Phone:586-307-4757
Mailing Address - Fax:855-393-6740
Practice Address - Street 1:50920 VAN DYKE AVE
Practice Address - Street 2:
Practice Address - City:SHELBY TWP
Practice Address - State:MI
Practice Address - Zip Code:48317-1367
Practice Address - Country:US
Practice Address - Phone:586-307-4757
Practice Address - Fax:855-393-6740
Is Sole Proprietor?:No
Enumeration Date:2019-05-16
Last Update Date:2024-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7101008829235Z00000X
106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician