Provider Demographics
NPI:1386606358
Name:GLINES, MANNIX GEORGE (LCSW)
Entity type:Individual
Prefix:
First Name:MANNIX
Middle Name:GEORGE
Last Name:GLINES
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6624 OLD MILL RD
Mailing Address - Street 2:
Mailing Address - City:STANSBURY PARK
Mailing Address - State:UT
Mailing Address - Zip Code:84074-9054
Mailing Address - Country:US
Mailing Address - Phone:801-824-3138
Mailing Address - Fax:
Practice Address - Street 1:6624 OLD MILL RD
Practice Address - Street 2:
Practice Address - City:STANSBURY PARK
Practice Address - State:UT
Practice Address - Zip Code:84074-9054
Practice Address - Country:US
Practice Address - Phone:801-824-3138
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-05
Last Update Date:2012-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT31821335011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT870641924OtherTAX ID NUMBER
UTU000076268Medicare PIN