MEDICARE: MR. JAMES ALEXANDER MANNIS LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	LCS19601	CA

General Provider Information

NPI Number	:	1255302188
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JAMES ALEXANDER MANNIS LCSW

Provider Business Mailing Address
First Line	:	10957 MONTONGO ST
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92126-2136
Country	:	US
Telephone Number	:	858-689-0964
Fax Number	:

Provider Business Practice Location Address
First Line	:	140 SYLVESTER RD
Second Line	:	SARP BLDG 500, RM 601
City	:	SAN DIEGO
State	:	CA
Zip	:	92106-3521
Country	:	US
Telephone Number	:	619-553-0535
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/30/2006
Last Update Date	:	07/08/2007

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