Provider Demographics
NPI:1932924594
Name:MANTRA LLC
Entity type:Organization
Organization Name:MANTRA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROFESSIONAL COUNSELOR
Authorized Official - Prefix:
Authorized Official - First Name:MATT
Authorized Official - Middle Name:
Authorized Official - Last Name:DEHOOG
Authorized Official - Suffix:
Authorized Official - Credentials:MA, LPC
Authorized Official - Phone:616-366-4226
Mailing Address - Street 1:326 EASTMOOR AVE SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-2227
Mailing Address - Country:US
Mailing Address - Phone:616-581-7687
Mailing Address - Fax:
Practice Address - Street 1:826 PARCHMENT DR SE STE 100
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-2307
Practice Address - Country:US
Practice Address - Phone:616-366-4226
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-11-19
Last Update Date:2024-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty