=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255302188
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JAMES ALEXANDER MANNIS LCSW
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/30/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 140 SYLVESTER RD SARP BLDG 500, RM 601
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92106-3521
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-553-0535
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10957 MONTONGO ST
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92126-2136
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 858-689-0964
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | LCS19601
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------