Provider Demographics
NPI:1750826780
Name:MANESS, MARK
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:MANESS
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 1:185 SUTTLE ST
Mailing Address - Street 2:
Mailing Address - City:DURANGO
Mailing Address - State:CO
Mailing Address - Zip Code:81303-8276
Mailing Address - Country:US
Mailing Address - Phone:970-335-2232
Mailing Address - Fax:970-335-2438
Practice Address - Street 1:691 E EMPIRE ST
Practice Address - Street 2:
Practice Address - City:CORTEZ
Practice Address - State:CO
Practice Address - Zip Code:81321-2802
Practice Address - Country:US
Practice Address - Phone:970-565-7946
Practice Address - Fax:970-565-9005
Is Sole Proprietor?:No
Enumeration Date:2016-12-29
Last Update Date:2020-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COACB.0006974101YA0400X
101YM0800X
CO0001279101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health