Healthcare Provider Details

I. General information

NPI: 1285686634
Provider Name (Legal Business Name): RACHAEL MANNEY LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/16/2006
Last Update Date: 09/01/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

809 JEFFERSON AVE
LA PORTE IN
46350-3431
US

IV. Provider business mailing address

809 JEFFERSON AVE
LA PORTE IN
46350-3431
US

V. Phone/Fax

Practice location:
  • Phone: 219-617-4599
  • Fax: 219-325-0855
Mailing address:
  • Phone: 219-617-4599
  • Fax: 219-325-0855

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number34004603A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: