Provider Demographics
NPI:1053443374
Name:MANTOOTH, DONNA BING (LPC)
Entity Type:Individual
Prefix:MRS
First Name:DONNA
Middle Name:BING
Last Name:MANTOOTH
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2722 BLACKS BLUFF RD SW
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:GA
Mailing Address - Zip Code:30161-4337
Mailing Address - Country:US
Mailing Address - Phone:706-295-4809
Mailing Address - Fax:
Practice Address - Street 1:55 INTERNATIONAL PKWY
Practice Address - Street 2:
Practice Address - City:ADAIRSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30103
Practice Address - Country:US
Practice Address - Phone:888-295-2974
Practice Address - Fax:770-773-3655
Is Sole Proprietor?:No
Enumeration Date:2007-03-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA3364101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional