Provider Demographics
NPI:1629510649
Name:MANN, SAMANTHA (PSYD)
Entity Type:Individual
Prefix:DR
First Name:SAMANTHA
Middle Name:
Last Name:MANN
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:255 CANYON BLVD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80302-4979
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:255 CANYON BLVD
Practice Address - Street 2:SUITE 200
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80302-4979
Practice Address - Country:US
Practice Address - Phone:303-474-4055
Practice Address - Fax:720-638-3699
Is Sole Proprietor?:No
Enumeration Date:2016-11-08
Last Update Date:2018-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPSY.0004481101Y00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101Y00000XBehavioral Health & Social Service ProvidersCounselor