Provider Demographics
NPI:1689721698
Name:BRANSON PSYCHOLOGICAL & DIAGNOSTIC SERVICES PC
Entity Type:Organization
Organization Name:BRANSON PSYCHOLOGICAL & DIAGNOSTIC SERVICES PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MARCI
Authorized Official - Middle Name:MICHELLE
Authorized Official - Last Name:MANNA
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:417-335-8466
Mailing Address - Street 1:574 STATE HIGHWAY 248
Mailing Address - Street 2:SUITE 3
Mailing Address - City:BRANSON
Mailing Address - State:MO
Mailing Address - Zip Code:65616-7740
Mailing Address - Country:US
Mailing Address - Phone:417-335-8466
Mailing Address - Fax:417-335-8566
Practice Address - Street 1:574 STATE HIGHWAY 248
Practice Address - Street 2:SUITE 3
Practice Address - City:BRANSON
Practice Address - State:MO
Practice Address - Zip Code:65616-7740
Practice Address - Country:US
Practice Address - Phone:417-335-8466
Practice Address - Fax:417-335-8566
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-04
Last Update Date:2011-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOPYO1867103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO499660603Medicaid
MO000070895Medicare ID - Type Unspecified