1679805469 NPI number — MS. ELIZABETH MANTLE MFT, LPCC

Table of content: MS. ELIZABETH MANTLE MFT, LPCC (NPI 1679805469)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679805469 NPI number — MS. ELIZABETH MANTLE MFT, LPCC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MANTLE
Provider First Name:
ELIZABETH
Provider Middle Name:
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
MFT, LPCC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MANTLE
Provider Other First Name:
LIZ
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MFT, LPCC
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1679805469
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/04/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 2272
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NEVADA CITY
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95959-1945
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
530-355-1467
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
768 WOODLAND WAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GRASS VALLEY
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95945-7864
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
530-355-1467
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/04/2010

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 106H00000X , with the licence number:  MFC 35631 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 101YP2500X , with the licence number: LPCC 553 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)