Basic Information
| Provider Information | |||||||||
| NPI: | 1750625372 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MANNIA | ||||||||
| FirstName: | MICHELLE | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PSYD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | LESLIE | ||||||||
| OtherFirstName: | MICHELLE | ||||||||
| OtherMiddleName: | L | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PSYD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 4507 EAGLE CREEK PKWY | ||||||||
| Address2: | UNIT 310 | ||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462544374 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5742769556 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 6640 INTECH BLVD | ||||||||
| Address2: | STE 195 | ||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462782011 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3172950608 | ||||||||
| FaxNumber: | 3172950622 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/20/2012 | ||||||||
| LastUpdateDate: | 07/17/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 39002420A | IN | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 103TC0700X | 20042755A | IN | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 201228760 | 05 | IN | MEDICAID |