Provider Demographics
NPI:1992056857
Name:MANTIS, BETH W (LMT)
Entity type:Individual
Prefix:
First Name:BETH
Middle Name:W
Last Name:MANTIS
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29544 SE HEIPLE RD
Mailing Address - Street 2:
Mailing Address - City:EAGLE CREEK
Mailing Address - State:OR
Mailing Address - Zip Code:97022-9664
Mailing Address - Country:US
Mailing Address - Phone:503-887-6070
Mailing Address - Fax:503-630-2860
Practice Address - Street 1:29544 SE HEIPLE RD
Practice Address - Street 2:
Practice Address - City:EAGLE CREEK
Practice Address - State:OR
Practice Address - Zip Code:97022-9664
Practice Address - Country:US
Practice Address - Phone:503-887-6070
Practice Address - Fax:503-630-2860
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-01
Last Update Date:2012-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR18018225400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner