Provider Demographics
NPI:1053582650
Name:MANN, MICHAELA B (LMP)
Entity type:Individual
Prefix:
First Name:MICHAELA
Middle Name:B
Last Name:MANN
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24751 N CROSBY RD
Mailing Address - Street 2:
Mailing Address - City:PROSSER
Mailing Address - State:WA
Mailing Address - Zip Code:99350-8640
Mailing Address - Country:US
Mailing Address - Phone:509-786-7109
Mailing Address - Fax:
Practice Address - Street 1:1212 MEADE AVE
Practice Address - Street 2:
Practice Address - City:PROSSER
Practice Address - State:WA
Practice Address - Zip Code:99350-1482
Practice Address - Country:US
Practice Address - Phone:509-947-0459
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-21
Last Update Date:2008-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00014200225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist