Provider Demographics
NPI:1740645951
Name:MANASSA, LAURA M (MACP)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:M
Last Name:MANASSA
Suffix:
Gender:F
Credentials:MACP
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:
Other - Last Name:ROGERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 54723
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32245-4723
Mailing Address - Country:US
Mailing Address - Phone:904-239-3677
Mailing Address - Fax:904-239-3278
Practice Address - Street 1:1540 KINGSLEY AVE
Practice Address - Street 2:
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32073-4511
Practice Address - Country:US
Practice Address - Phone:904-239-3677
Practice Address - Fax:904-239-3278
Is Sole Proprietor?:No
Enumeration Date:2015-12-15
Last Update Date:2015-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH5784101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health