Healthcare Provider Details

I. General information

NPI: 1750625372
Provider Name (Legal Business Name): MICHELLE L MANNIA PSYD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MICHELLE L LESLIE PSYD

II. Dates (important events)

Enumeration Date: 11/20/2012
Last Update Date: 07/17/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6640 INTECH BLVD STE 195
INDIANAPOLIS IN
46278-2011
US

IV. Provider business mailing address

4507 EAGLE CREEK PKWY UNIT 310
INDIANAPOLIS IN
46254-4374
US

V. Phone/Fax

Practice location:
  • Phone: 317-295-0608
  • Fax: 317-295-0622
Mailing address:
  • Phone: 574-276-9556
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number39002420A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number20042755A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: