Provider Demographics
NPI:1740206184
Name:MANN, IRENE T (PHD)
Entity Type:Individual
Prefix:
First Name:IRENE
Middle Name:T
Last Name:MANN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5360 HOLIDAY TER
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49009-2126
Mailing Address - Country:US
Mailing Address - Phone:269-353-3063
Mailing Address - Fax:269-353-3069
Practice Address - Street 1:5360 HOLIDAY TER
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49009-2126
Practice Address - Country:US
Practice Address - Phone:269-353-3063
Practice Address - Fax:269-353-3069
Is Sole Proprietor?:No
Enumeration Date:2006-07-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301007832103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
098983OtherMANAGED HEALTH NETWORK
MI680C94696OtherBCBS OF MICHIGAN
MI680C94696OtherBCBS OF MICHIGAN
0M44110Medicare ID - Type Unspecified