Provider Demographics
NPI:1003093915
Name:MANTOOTH, JANIE M (LCSW)
Entity Type:Individual
Prefix:MS
First Name:JANIE
Middle Name:M
Last Name:MANTOOTH
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 628
Mailing Address - Street 2:
Mailing Address - City:BEDFORD
Mailing Address - State:VA
Mailing Address - Zip Code:24523-0628
Mailing Address - Country:US
Mailing Address - Phone:540-586-8146
Mailing Address - Fax:540-587-7647
Practice Address - Street 1:1020 TURKEY MOUNTAIN RD
Practice Address - Street 2:
Practice Address - City:BEDFORD
Practice Address - State:VA
Practice Address - Zip Code:24523-6635
Practice Address - Country:US
Practice Address - Phone:540-586-8146
Practice Address - Fax:540-587-7647
Is Sole Proprietor?:No
Enumeration Date:2008-01-23
Last Update Date:2008-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040039791041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
010219779OtherVIRGINIA PREMIER
183482OtherANTHEM
338400OtherVALUE OPTIONS
VA010219779Medicaid
233212OtherCOMPSYCH CORP
7664336OtherAETNA
010219779OtherVIRGINIA PREMIER