Provider Demographics
NPI:1790904969
Name:MANZON, VICTOR JOHN (LMSW)
Entity Type:Individual
Prefix:MR
First Name:VICTOR
Middle Name:JOHN
Last Name:MANZON
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 2588
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49081-2588
Mailing Address - Country:US
Mailing Address - Phone:269-341-4422
Mailing Address - Fax:269-341-4433
Practice Address - Street 1:834 KING HIGHWAY
Practice Address - Street 2:SUITE 106
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49001-2578
Practice Address - Country:US
Practice Address - Phone:269-341-4422
Practice Address - Fax:269-341-4433
Is Sole Proprietor?:No
Enumeration Date:2007-04-25
Last Update Date:2011-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010597721041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical