Provider Demographics
NPI:1447374749
Name:MANNNIXON, VANESSA D (LLBSW/CAC-M)
Entity type:Individual
Prefix:MS
First Name:VANESSA
Middle Name:D
Last Name:MANNNIXON
Suffix:
Gender:F
Credentials:LLBSW/CAC-M
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31097 WARREN RD APT 108
Mailing Address - Street 2:
Mailing Address - City:WESTLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48185-2964
Mailing Address - Country:US
Mailing Address - Phone:734-261-5106
Mailing Address - Fax:
Practice Address - Street 1:3737 LAWTON ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48208-2500
Practice Address - Country:US
Practice Address - Phone:313-361-6136
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-19
Last Update Date:2008-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI381737643101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1811094998Medicaid