Provider Demographics
NPI:1770647166
Name:MANNELLI, DAVID FREDERIC (PSYD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:FREDERIC
Last Name:MANNELLI
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:223 PECKS CT
Mailing Address - Street 2:
Mailing Address - City:WALWORTH
Mailing Address - State:WI
Mailing Address - Zip Code:53184-9664
Mailing Address - Country:US
Mailing Address - Phone:414-702-0080
Mailing Address - Fax:262-542-0823
Practice Address - Street 1:741 N GRAND AVE STE 302
Practice Address - Street 2:
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53186-4820
Practice Address - Country:US
Practice Address - Phone:262-542-3255
Practice Address - Fax:262-542-0823
Is Sole Proprietor?:No
Enumeration Date:2006-12-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2280-057103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical