Provider Demographics
NPI:1518983295
Name:MANNS, GLORIA POLK (LCSW)
Entity Type:Individual
Prefix:
First Name:GLORIA
Middle Name:POLK
Last Name:MANNS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1604 ROANOKE BLVD
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:VA
Mailing Address - Zip Code:24153-6420
Mailing Address - Country:US
Mailing Address - Phone:540-375-7620
Mailing Address - Fax:540-375-7621
Practice Address - Street 1:1604 ROANOKE BLVD
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:VA
Practice Address - Zip Code:24153-6420
Practice Address - Country:US
Practice Address - Phone:540-375-7620
Practice Address - Fax:540-375-7621
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-14
Last Update Date:2008-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040019471041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA008946086Medicaid
VA190000625Medicare PIN