Provider Demographics
NPI:1508573312
Name:MANSON, TONY G
Entity type:Individual
Prefix:MR
First Name:TONY
Middle Name:G
Last Name:MANSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:950 PARK BLVD
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92101-6529
Mailing Address - Country:US
Mailing Address - Phone:619-930-1008
Mailing Address - Fax:
Practice Address - Street 1:2516 A ST
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92102-2199
Practice Address - Country:US
Practice Address - Phone:619-235-0592
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-01
Last Update Date:2024-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
175T00000X
CA101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No175T00000XOther Service ProvidersPeer Specialist