Provider Demographics
NPI:1972756005
Name:MANI, TANJA (PHD)
Entity type:Individual
Prefix:
First Name:TANJA
Middle Name:
Last Name:MANI
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2147
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33902-2147
Mailing Address - Country:US
Mailing Address - Phone:239-343-9220
Mailing Address - Fax:239-343-9231
Practice Address - Street 1:12600 CREEKSIDE LN STE 7
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33919-3353
Practice Address - Country:US
Practice Address - Phone:239-343-9220
Practice Address - Fax:239-343-4240
Is Sole Proprietor?:No
Enumeration Date:2008-11-03
Last Update Date:2024-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY7833103T00000X, 103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL105805000Medicaid