Provider Demographics
NPI:1306931167
Name:MANN, PAVANINDER S (PHD)
Entity type:Individual
Prefix:
First Name:PAVANINDER
Middle Name:S
Last Name:MANN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:PAVAN
Other - Middle Name:
Other - Last Name:MANN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:9114 ADAMS AVENUE
Mailing Address - Street 2:179
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92646
Mailing Address - Country:US
Mailing Address - Phone:714-609-6547
Mailing Address - Fax:
Practice Address - Street 1:3151 AIRWAY AVENUE
Practice Address - Street 2:SUITE T3
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92626
Practice Address - Country:US
Practice Address - Phone:714-545-5550
Practice Address - Fax:714-545-5748
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2011-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY18296103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACP18296AMedicare ID - Type Unspecified