Provider Demographics
NPI:1164581716
Name:MANTYLA, JOUNI (PT)
Entity Type:Individual
Prefix:
First Name:JOUNI
Middle Name:
Last Name:MANTYLA
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10860 HIGHLAND RD
Practice Address - Street 2:
Practice Address - City:HARTLAND
Practice Address - State:MI
Practice Address - Zip Code:48353-2629
Practice Address - Country:US
Practice Address - Phone:810-632-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-08
Last Update Date:2014-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501005525225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP00079943OtherRR MEDICARE
MIP01352505OtherRAILROAD MEDICARE
MIP01352505OtherRAILROAD MEDICARE
MIJM00525OtherBLUE CARE NETWORK
MIP00079943OtherRR MEDICARE