MEDICARE: URSULA E. MANN L.C.S.W.

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	LCSW 10404	AZ

General Provider Information

NPI Number	:	1316061161
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	URSULA E. MANN L.C.S.W.

Provider Business Mailing Address
First Line	:	257 JUSTIN DR, #B
Second Line	:
City	:	COTTONWOOD
State	:	AZ
Zip	:	86326
Country	:	US
Telephone Number	:	928-649-9808
Fax Number	:

Provider Business Practice Location Address
First Line	:	257 JUSTIN DR, #B
Second Line	:
City	:	COTTONWOOD
State	:	AZ
Zip	:	86326-0000
Country	:	US
Telephone Number	:	928-649-9808
Fax Number	:

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

Provider Enumeration Date	:	03/19/2007
Last Update Date	:	07/08/2007

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