Provider Demographics
NPI:1073016101
Name:MANN, TRISHA DYAN (PHD)
Entity Type:Individual
Prefix:DR
First Name:TRISHA
Middle Name:DYAN
Last Name:MANN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 N REGENCY DR
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61701-3570
Mailing Address - Country:US
Mailing Address - Phone:309-661-8046
Mailing Address - Fax:
Practice Address - Street 1:103 N REGENCY DR
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61701-3570
Practice Address - Country:US
Practice Address - Phone:309-661-8046
Practice Address - Fax:309-661-8093
Is Sole Proprietor?:No
Enumeration Date:2018-03-15
Last Update Date:2018-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071.009707103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical