Provider Demographics
NPI:1750625372
Name:MANNIA, MICHELLE L (PSYD)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:L
Last Name:MANNIA
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:L
Other - Last Name:LESLIE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PSYD
Mailing Address - Street 1:4507 EAGLE CREEK PKWY
Mailing Address - Street 2:UNIT 310
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46254-4374
Mailing Address - Country:US
Mailing Address - Phone:574-276-9556
Mailing Address - Fax:
Practice Address - Street 1:6640 INTECH BLVD
Practice Address - Street 2:STE 195
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46278-2011
Practice Address - Country:US
Practice Address - Phone:317-295-0608
Practice Address - Fax:317-295-0622
Is Sole Proprietor?:No
Enumeration Date:2012-11-20
Last Update Date:2014-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN39002420A101YM0800X
IN20042755A103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201228760Medicaid
IN201228760Medicaid