Provider Demographics
NPI:1699360883
Name:MANN, CORY SHANE
Entity Type:Individual
Prefix:MR
First Name:CORY
Middle Name:SHANE
Last Name:MANN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1360 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BISHOP
Mailing Address - State:CA
Mailing Address - Zip Code:93514-3013
Mailing Address - Country:US
Mailing Address - Phone:760-873-5577
Mailing Address - Fax:
Practice Address - Street 1:1360 N MAIN ST
Practice Address - Street 2:
Practice Address - City:BISHOP
Practice Address - State:CA
Practice Address - Zip Code:93514-3013
Practice Address - Country:US
Practice Address - Phone:760-873-5577
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-09
Last Update Date:2022-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
376J00000X
CACI33360721101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No376J00000XNursing Service Related ProvidersHomemaker