Provider Demographics
NPI:1679662134
Name:MANZ, JOHN (LICSW / MDIV)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:MANZ
Suffix:
Gender:M
Credentials:LICSW / MDIV
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:590 PARK ST
Mailing Address - Street 2:STE 310
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55103-1846
Mailing Address - Country:US
Mailing Address - Phone:651-310-9428
Mailing Address - Fax:651-227-2797
Practice Address - Street 1:590 PARK ST
Practice Address - Street 2:STE 310
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55103-1846
Practice Address - Country:US
Practice Address - Phone:651-310-9428
Practice Address - Fax:651-227-2797
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN068851041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical