Provider Demographics
NPI:1487188140
Name:MANSEL, DEIRDRE TARA
Entity Type:Individual
Prefix:
First Name:DEIRDRE
Middle Name:TARA
Last Name:MANSEL
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 1:3645 HIGHWAY 43 S
Mailing Address - Street 2:
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:TN
Mailing Address - Zip Code:38481-7010
Mailing Address - Country:US
Mailing Address - Phone:256-367-0091
Mailing Address - Fax:
Practice Address - Street 1:1090 OLD FLORENCE RD
Practice Address - Street 2:
Practice Address - City:LAWRENCEBURG
Practice Address - State:TN
Practice Address - Zip Code:38464-8401
Practice Address - Country:US
Practice Address - Phone:931-762-6505
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-19
Last Update Date:2017-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist