Provider Demographics
NPI:1588752927
Name:MANTELLO, LAURA MIA
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:MIA
Last Name:MANTELLO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:259 MASALIN RD
Mailing Address - Street 2:
Mailing Address - City:LINCOLNVILLE
Mailing Address - State:ME
Mailing Address - Zip Code:04849-5538
Mailing Address - Country:US
Mailing Address - Phone:207-763-4243
Mailing Address - Fax:
Practice Address - Street 1:259 MASALIN RD
Practice Address - Street 2:
Practice Address - City:LINCOLNVILLE
Practice Address - State:ME
Practice Address - Zip Code:04849-5538
Practice Address - Country:US
Practice Address - Phone:207-763-4243
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MECC1532101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health