Provider Demographics
NPI:1427821826
Name:FORTIN MANNINEN, MELISA (LCSW)
Entity type:Individual
Prefix:
First Name:MELISA
Middle Name:
Last Name:FORTIN MANNINEN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1122 VIA SE VILLA
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78260-4200
Mailing Address - Country:US
Mailing Address - Phone:240-460-0034
Mailing Address - Fax:
Practice Address - Street 1:1122 VIA SE VILLA
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78260-4200
Practice Address - Country:US
Practice Address - Phone:240-460-0034
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-07
Last Update Date:2023-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1034221041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical