Provider Demographics
NPI:1063955508
Name:MANTIA, ROBERT (MA, LPCC)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:
Last Name:MANTIA
Suffix:
Gender:M
Credentials:MA, LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:470 HIGHWAY 96 W STE 260
Mailing Address - Street 2:
Mailing Address - City:SHOREVIEW
Mailing Address - State:MN
Mailing Address - Zip Code:55126-3216
Mailing Address - Country:US
Mailing Address - Phone:651-237-3767
Mailing Address - Fax:
Practice Address - Street 1:470 HIGHWAY 96 W STE 260
Practice Address - Street 2:
Practice Address - City:SHOREVIEW
Practice Address - State:MN
Practice Address - Zip Code:55126-3216
Practice Address - Country:US
Practice Address - Phone:651-237-3767
Practice Address - Fax:651-236-8033
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-01
Last Update Date:2024-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNCC01387101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional