Provider Demographics
NPI:1699495549
Name:MANN, CLINTON THOMAS
Entity type:Individual
Prefix:
First Name:CLINTON
Middle Name:THOMAS
Last Name:MANN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2432 W PEORIA AVE STE 1114
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85029-4732
Mailing Address - Country:US
Mailing Address - Phone:602-999-0028
Mailing Address - Fax:
Practice Address - Street 1:2432 W PEORIA AVE STE 1114
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85029-4732
Practice Address - Country:US
Practice Address - Phone:602-999-0028
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-31
Last Update Date:2022-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ86-0586210175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZD05124188OtherIDENTIFICATION CARD