Provider Demographics
NPI:1154684306
Name:MANTILLA, LOURDES (MSW)
Entity Type:Individual
Prefix:MS
First Name:LOURDES
Middle Name:
Last Name:MANTILLA
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:SECTOR GALATEO ALTO BUZON 186 RUTA 5
Mailing Address - Street 2:
Mailing Address - City:ISABELA
Mailing Address - State:PR
Mailing Address - Zip Code:00662
Mailing Address - Country:US
Mailing Address - Phone:787-518-2773
Mailing Address - Fax:
Practice Address - Street 1:BUZON 5- 186 GALATEO ALTO
Practice Address - Street 2:
Practice Address - City:ISABELA
Practice Address - State:PR
Practice Address - Zip Code:00662
Practice Address - Country:US
Practice Address - Phone:787-518-2773
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-22
Last Update Date:2012-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR172321041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR17232OtherSOCIAL WORKER LIC