Provider Demographics
NPI:1598194813
Name:MANN, LAURA
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:MANN
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 1:195 POPLAR PL
Mailing Address - Street 2:1720 N RANDALL RD
Mailing Address - City:NORTH AURORA
Mailing Address - State:IL
Mailing Address - Zip Code:60542-1404
Mailing Address - Country:US
Mailing Address - Phone:630-907-2400
Mailing Address - Fax:
Practice Address - Street 1:122 N COUNTRY CLUB DR
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85201-6522
Practice Address - Country:US
Practice Address - Phone:480-308-7320
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-11-06
Last Update Date:2013-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ4230103TC0700X
IL071-003977103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical