Provider Demographics
NPI:1528206182
Name:MANN, SHELLY ANN (LCSW)
Entity type:Individual
Prefix:
First Name:SHELLY
Middle Name:ANN
Last Name:MANN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:SHELLY
Other - Middle Name:
Other - Last Name:GOMEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:PO BOX 949
Mailing Address - Street 2:
Mailing Address - City:SLIDELL
Mailing Address - State:LA
Mailing Address - Zip Code:70459-0949
Mailing Address - Country:US
Mailing Address - Phone:985-285-6059
Mailing Address - Fax:888-740-5909
Practice Address - Street 1:2013 CLAIBORNE ST
Practice Address - Street 2:
Practice Address - City:MANDEVILLE
Practice Address - State:LA
Practice Address - Zip Code:70448-5804
Practice Address - Country:US
Practice Address - Phone:985-285-6059
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-04
Last Update Date:2024-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSC75701041C0700X
LA88461041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA3426374Medicaid