Provider Demographics
NPI:1003915711
Name:MANN, SAMANTHA
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:MANN
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 1:3997 BECKLEY RD
Mailing Address - Street 2:
Mailing Address - City:PRINCETON
Mailing Address - State:WV
Mailing Address - Zip Code:24740-7660
Mailing Address - Country:US
Mailing Address - Phone:304-431-5499
Mailing Address - Fax:304-431-3400
Practice Address - Street 1:3997 BECKLEY ROAD
Practice Address - Street 2:
Practice Address - City:PRINCETON
Practice Address - State:WV
Practice Address - Zip Code:24740
Practice Address - Country:US
Practice Address - Phone:304-431-5499
Practice Address - Fax:304-431-3400
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-21
Last Update Date:2014-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV757103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist