Basic Information
| Provider Information | |||||||||
| NPI: | 1740291863 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MANN | ||||||||
| FirstName: | MARILYN | ||||||||
| MiddleName: | SUE | ||||||||
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| Credential: | MSW LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 33 | ||||||||
| Address2: | |||||||||
| City: | EVANSVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 477010033 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8124730181 | ||||||||
| FaxNumber: | 8124735822 | ||||||||
| Practice Location | |||||||||
| Address1: | 15 VANN AVE | ||||||||
| Address2: | |||||||||
| City: | EVANSVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 477141444 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8124028333 | ||||||||
| FaxNumber: | 8124028331 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/11/2006 | ||||||||
| LastUpdateDate: | 02/03/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 34004276A | IN | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 000000920809 | 01 | IN | ANTHEM BCBS | OTHER | P01473497 | 01 | RAILROAD MEDICARE | OTHER |