=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336594274
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TIMARA MANNS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/28/2016
-----------------------------------------------------
Last Update Date | 04/28/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 401 MAIN ST SUITE 108
-----------------------------------------------------
City | ISLIP
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11751-3560
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-446-1950
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 549 NORTHERN PKWY
-----------------------------------------------------
City | UNIONDALE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11553-2833
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 347-476-6074
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number | 096447
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------