Provider Demographics
NPI:1922780634
Name:MANIS, MIRANDA (MSW)
Entity type:Individual
Prefix:
First Name:MIRANDA
Middle Name:
Last Name:MANIS
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9111 BROADWAY STE JJ
Mailing Address - Street 2:
Mailing Address - City:MERRILLVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46410-7002
Mailing Address - Country:US
Mailing Address - Phone:219-216-3605
Mailing Address - Fax:
Practice Address - Street 1:9111 BROADWAY STE JJ
Practice Address - Street 2:
Practice Address - City:MERRILLVILLE
Practice Address - State:IN
Practice Address - Zip Code:46410-7002
Practice Address - Country:US
Practice Address - Phone:219-216-3605
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-02
Last Update Date:2025-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34012084A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical