Provider Demographics
NPI:1689725277
Name:MANOSEVITZ, MARTIN (PHD)
Entity Type:Individual
Prefix:DR
First Name:MARTIN
Middle Name:
Last Name:MANOSEVITZ
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 7976
Mailing Address - Street 2:
Mailing Address - City:ASPEN
Mailing Address - State:CO
Mailing Address - Zip Code:81612-7976
Mailing Address - Country:US
Mailing Address - Phone:970-925-2552
Mailing Address - Fax:970-963-7217
Practice Address - Street 1:225 N MILL ST
Practice Address - Street 2:# 206
Practice Address - City:ASPEN
Practice Address - State:CO
Practice Address - Zip Code:81611-1559
Practice Address - Country:US
Practice Address - Phone:970-925-2552
Practice Address - Fax:970-963-7217
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2262103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO461078Medicare ID - Type UnspecifiedPSYCHOLOGIST