Provider Demographics
NPI:1497464499
Name:MANN, SHELLIENE BRIANNE (SUDPT)
Entity Type:Individual
Prefix:
First Name:SHELLIENE
Middle Name:BRIANNE
Last Name:MANN
Suffix:
Gender:F
Credentials:SUDPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1301 B ST
Mailing Address - Street 2:
Mailing Address - City:CENTRALIA
Mailing Address - State:WA
Mailing Address - Zip Code:98531-5007
Mailing Address - Country:US
Mailing Address - Phone:360-791-0866
Mailing Address - Fax:
Practice Address - Street 1:6005 TYEE DR SW
Practice Address - Street 2:
Practice Address - City:TUMWATER
Practice Address - State:WA
Practice Address - Zip Code:98512-7356
Practice Address - Country:US
Practice Address - Phone:360-464-6872
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-17
Last Update Date:2022-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA61255065101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)