Healthcare Provider Details

I. General information

NPI: 1508573312
Provider Name (Legal Business Name): MR. TONY G MANSON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/01/2022
Last Update Date: 07/13/2024
Certification Date: 07/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2516 A ST
SAN DIEGO CA
92102-2199
US

IV. Provider business mailing address

950 PARK BLVD
SAN DIEGO CA
92101-6529
US

V. Phone/Fax

Practice location:
  • Phone: 619-235-0592
  • Fax:
Mailing address:
  • Phone: 619-930-1008
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: