Provider Demographics
NPI:1457640021
Name:MANN, MARC JEFFREY (PHD)
Entity Type:Individual
Prefix:
First Name:MARC
Middle Name:JEFFREY
Last Name:MANN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:434 PROSPECT ST
Mailing Address - Street 2:
Mailing Address - City:TORRINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06790-4937
Mailing Address - Country:US
Mailing Address - Phone:860-329-6357
Mailing Address - Fax:561-658-6120
Practice Address - Street 1:434 PROSPECT ST
Practice Address - Street 2:
Practice Address - City:TORRINGTON
Practice Address - State:CT
Practice Address - Zip Code:06790-4937
Practice Address - Country:US
Practice Address - Phone:860-329-6357
Practice Address - Fax:561-658-6120
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-04
Last Update Date:2011-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT3098103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical