Provider Demographics
NPI:1710397997
Name:MANN, MISTY MARIE (PSYD)
Entity type:Individual
Prefix:DR
First Name:MISTY
Middle Name:MARIE
Last Name:MANN
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:222 MERCHANDISE MART PLZ STE 1358
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60654-1103
Mailing Address - Country:US
Mailing Address - Phone:317-752-0301
Mailing Address - Fax:
Practice Address - Street 1:222 MERCHANDISE MART PLZ STE 1358
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60654-1103
Practice Address - Country:US
Practice Address - Phone:317-752-0301
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-28
Last Update Date:2014-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071008814103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical