Provider Demographics
NPI:1124594502
Name:MANTIA, KIMBERLY (CP60821274)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:MANTIA
Suffix:
Gender:F
Credentials:CP60821274
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1061 EAGLE CREST PL
Mailing Address - Street 2:
Mailing Address - City:PORT ORCHARD
Mailing Address - State:WA
Mailing Address - Zip Code:98366-3632
Mailing Address - Country:US
Mailing Address - Phone:360-440-2949
Mailing Address - Fax:
Practice Address - Street 1:9601 BUJACICH RD NW
Practice Address - Street 2:
Practice Address - City:GIG HARBOR
Practice Address - State:WA
Practice Address - Zip Code:98332-8300
Practice Address - Country:US
Practice Address - Phone:360-440-2949
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-23
Last Update Date:2018-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACP60821274101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)