Basic Information
| Provider Information | |||||||||
| NPI: | 1679800130 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MANNING | ||||||||
| FirstName: | GARY | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | LSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 15585 STATE ROUTE 550 | ||||||||
| Address2: | |||||||||
| City: | FLEMING | ||||||||
| State: | OH | ||||||||
| PostalCode: | 457295058 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 207 COLEGATE DR | ||||||||
| Address2: | |||||||||
| City: | MARIETTA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 457502363 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7403760930 | ||||||||
| FaxNumber: | 7403760933 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/04/2009 | ||||||||
| LastUpdateDate: | 11/04/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | S.0800530 | OH | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.