1659852093 NPI number — ROBERT MANTELL, RN, PHD, LICENSED PSYCHOLOGIST

Table of content: (NPI 1659852093)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1659852093 NPI number — ROBERT MANTELL, RN, PHD, LICENSED PSYCHOLOGIST

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ROBERT MANTELL, RN, PHD, LICENSED PSYCHOLOGIST
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1659852093
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/23/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1549 BRANSTON ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAINT PAUL
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55108-1437
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
651-503-6322
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
821 RAYMOND AVE STE 330
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAINT PAUL
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55114-1510
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
651-503-6322
Provider Business Practice Location Address Fax Number:
651-642-1506
Provider Enumeration Date:
08/23/2018

Additional Information

Authorized Official

Authorized Official Last Name:
MANTELL
Authorized Official First Name:
ROBERT
Authorized Official Middle Name:
ALAN
Authorized Official Title or Position:
PSYCHOLOGIST
Authorized Official Telephone Number:
651-503-6322

Provider Taxonomy Codes

  • Taxonomy code: 103TC1900X , with the licence number:  LP4396 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





Copyright © 2007-2025 www.npivalidator.com