Provider Demographics
NPI:1184004335
Name:MANTILLA, MADELINE (MS)
Entity Type:Individual
Prefix:MRS
First Name:MADELINE
Middle Name:
Last Name:MANTILLA
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:180 FAIRFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06604-4252
Mailing Address - Country:US
Mailing Address - Phone:203-394-6529
Mailing Address - Fax:203-384-8835
Practice Address - Street 1:401 SHIPPAN AVE
Practice Address - Street 2:
Practice Address - City:STAMFORD
Practice Address - State:CT
Practice Address - Zip Code:06902-6075
Practice Address - Country:US
Practice Address - Phone:203-517-3375
Practice Address - Fax:203-353-1524
Is Sole Proprietor?:No
Enumeration Date:2015-06-03
Last Update Date:2019-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT003667101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional