Provider Demographics
NPI:1235599036
Name:MANN, CONNIE (MFT)
Entity type:Individual
Prefix:
First Name:CONNIE
Middle Name:
Last Name:MANN
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 RANCHO LN
Mailing Address - Street 2:
Mailing Address - City:PETALUMA
Mailing Address - State:CA
Mailing Address - Zip Code:94952-1031
Mailing Address - Country:US
Mailing Address - Phone:415-609-5579
Mailing Address - Fax:
Practice Address - Street 1:201 ALAMEDA DEL PRADO STE 103
Practice Address - Street 2:
Practice Address - City:NOVATO
Practice Address - State:CA
Practice Address - Zip Code:94949-6698
Practice Address - Country:US
Practice Address - Phone:415-246-4671
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-07
Last Update Date:2024-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA92026101YM0800X
CA93766106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health