Provider Demographics
NPI:1114021821
Name:MANTELL, IRENE (LCSW)
Entity Type:Individual
Prefix:
First Name:IRENE
Middle Name:
Last Name:MANTELL
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MS
Other - First Name:AVERY
Other - Middle Name:
Other - Last Name:HART
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW
Mailing Address - Street 1:5 CHERRY TREE LN
Mailing Address - Street 2:
Mailing Address - City:KINNELON
Mailing Address - State:NJ
Mailing Address - Zip Code:07405-2214
Mailing Address - Country:US
Mailing Address - Phone:973-492-3404
Mailing Address - Fax:
Practice Address - Street 1:5 CHERRY TREE LN
Practice Address - Street 2:
Practice Address - City:KINNELON
Practice Address - State:NJ
Practice Address - Zip Code:07405-2214
Practice Address - Country:US
Practice Address - Phone:973-492-3404
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SC045788001041C0700X
NY052408-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ065144Medicare ID - Type Unspecified