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General NPI Number Information
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NPI Number | 1689721698
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Entity Type | Organization
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Legal Business Name | BRANSON PSYCHOLOGICAL & DIAGNOSTIC SERVICES PC
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Dates
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Enumeration Date | 01/04/2007
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Last Update Date | 03/25/2011
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Provider Practice Location Address
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Address Line | 574 STATE HIGHWAY 248 SUITE 3
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City | BRANSON
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State | MO
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Zip | 65616-7740
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Country | US
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Telephone | 417-335-8466
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Fax | 417-335-8566
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Provider Business Mailing Address
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Address Line | 574 STATE HIGHWAY 248 SUITE 3
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City | BRANSON
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State | MO
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Zip | 65616-7740
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Country | US
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Telephone | 417-335-8466
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Fax | 417-335-8566
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Authorized Official
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Title or Position | CLINICAL PSYCHOLOGIST
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Name | DR. MARCI MICHELLE MANNA
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Credential | PSY.D.
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Telephone | 417-335-8466
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | PYO1867
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License Number State | MO
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