Provider Demographics
NPI:1235599036
Name:MANN, CONNIE (MFTI)
Entity Type:Individual
Prefix:
First Name:CONNIE
Middle Name:
Last Name:MANN
Suffix:
Gender:F
Credentials:MFTI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 RANCHO LN
Mailing Address - Street 2:
Mailing Address - City:PETALUMA
Mailing Address - State:CA
Mailing Address - Zip Code:94952-1031
Mailing Address - Country:US
Mailing Address - Phone:415-609-5579
Mailing Address - Fax:
Practice Address - Street 1:555 NORTHGATE DR
Practice Address - Street 2:SUITE 200
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94903-3680
Practice Address - Country:US
Practice Address - Phone:415-457-6966
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-07
Last Update Date:2016-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA92026101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health