Provider Demographics
NPI:1215240536
Name:MANTILLA, CRISTINA (MA, LMHC)
Entity type:Individual
Prefix:MISS
First Name:CRISTINA
Middle Name:
Last Name:MANTILLA
Suffix:
Gender:F
Credentials:MA, LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5745 MAIN ST
Mailing Address - Street 2:SUITE 202
Mailing Address - City:NEW PORT RICHEY
Mailing Address - State:FL
Mailing Address - Zip Code:34652-2737
Mailing Address - Country:US
Mailing Address - Phone:727-967-7494
Mailing Address - Fax:866-926-7270
Practice Address - Street 1:5745 MAIN ST
Practice Address - Street 2:SUITE 202
Practice Address - City:NEW PORT RICHEY
Practice Address - State:FL
Practice Address - Zip Code:34652-2737
Practice Address - Country:US
Practice Address - Phone:727-967-7494
Practice Address - Fax:866-926-7270
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-15
Last Update Date:2013-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMI10384101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL003953800Medicaid