Provider Demographics
NPI:1255892352
Name:MANN, RAYMOND EDWARD (LCDCIII141050)
Entity type:Individual
Prefix:
First Name:RAYMOND
Middle Name:EDWARD
Last Name:MANN
Suffix:
Gender:M
Credentials:LCDCIII141050
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1066 BELLFLOWER AVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43204-2711
Mailing Address - Country:US
Mailing Address - Phone:740-877-6260
Mailing Address - Fax:
Practice Address - Street 1:100 HIGHVIEW BLVD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43207-6023
Practice Address - Country:US
Practice Address - Phone:614-826-9995
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-29
Last Update Date:2019-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLCDCIII.141050101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)