Provider Demographics
NPI:1255699161
Name:MANN, MICAH J (MA, LADC)
Entity type:Individual
Prefix:
First Name:MICAH
Middle Name:J
Last Name:MANN
Suffix:
Gender:M
Credentials:MA, LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:37 BRIDLE DR
Mailing Address - Street 2:
Mailing Address - City:BARKHAMSTED
Mailing Address - State:CT
Mailing Address - Zip Code:06063-3425
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:434 PROSPECT ST
Practice Address - Street 2:
Practice Address - City:TORRINGTON
Practice Address - State:CT
Practice Address - Zip Code:06790-4937
Practice Address - Country:US
Practice Address - Phone:860-877-4320
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-27
Last Update Date:2012-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT689101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)