MEDICARE: MELISA FORTIN MANNINEN 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	103422	TX

General Provider Information

NPI Number	:	1427821826
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MELISA FORTIN MANNINEN LCSW

Provider Business Mailing Address
First Line	:	1122 VIA SE VILLA
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78260-4200
Country	:	US
Telephone Number	:	240-460-0034
Fax Number	:

Provider Business Practice Location Address
First Line	:	1122 VIA SE VILLA
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78260-4200
Country	:	US
Telephone Number	:	240-460-0034
Fax Number	:

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

Provider Enumeration Date	:	11/07/2023
Last Update Date	:	11/07/2023

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