Provider Demographics
NPI:1972241180
Name:MANTILLA, ANDREA (MS)
Entity type:Individual
Prefix:
First Name:ANDREA
Middle Name:
Last Name:MANTILLA
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:45 SW 9TH ST APT 3902
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33130-3986
Mailing Address - Country:US
Mailing Address - Phone:954-804-6480
Mailing Address - Fax:
Practice Address - Street 1:4330 W BROWARD BLVD STE I
Practice Address - Street 2:
Practice Address - City:PLANTATION
Practice Address - State:FL
Practice Address - Zip Code:33317-3753
Practice Address - Country:US
Practice Address - Phone:954-372-0423
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-26
Last Update Date:2022-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL19064101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health