Provider Demographics
NPI:1780867911
Name:MANOCK, MINDY (LAC)
Entity Type:Individual
Prefix:
First Name:MINDY
Middle Name:
Last Name:MANOCK
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:510 4TH ST S
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-1914
Mailing Address - Country:US
Mailing Address - Phone:701-476-7200
Mailing Address - Fax:701-476-7261
Practice Address - Street 1:510 4TH ST S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-1914
Practice Address - Country:US
Practice Address - Phone:701-476-7200
Practice Address - Fax:701-476-7261
Is Sole Proprietor?:No
Enumeration Date:2007-12-11
Last Update Date:2007-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND1563101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)