Provider Demographics
NPI:1588862775
Name:MANTZ, CHARLENE MARJORIE
Entity type:Individual
Prefix:MRS
First Name:CHARLENE
Middle Name:MARJORIE
Last Name:MANTZ
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 1:5139 US HIGHWAY 19
Mailing Address - Street 2:
Mailing Address - City:NEW PT RICHEY
Mailing Address - State:FL
Mailing Address - Zip Code:34652-3966
Mailing Address - Country:US
Mailing Address - Phone:727-849-6076
Mailing Address - Fax:
Practice Address - Street 1:5139 US HIGHWAY 19
Practice Address - Street 2:
Practice Address - City:NEW PT RICHEY
Practice Address - State:FL
Practice Address - Zip Code:34652-3966
Practice Address - Country:US
Practice Address - Phone:727-849-6076
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-10
Last Update Date:2008-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAS2621237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL610268900Medicaid