Provider Demographics
NPI:1376186957
Name:MANTOOTH-SEIP, CHARLOTTE (MA PHDC CDP DV NCAC2)
Entity Type:Individual
Prefix:MS
First Name:CHARLOTTE
Middle Name:
Last Name:MANTOOTH-SEIP
Suffix:
Gender:F
Credentials:MA PHDC CDP DV NCAC2
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:611 W A ST
Mailing Address - Street 2:
Mailing Address - City:YAKIMA
Mailing Address - State:WA
Mailing Address - Zip Code:98902-2605
Mailing Address - Country:US
Mailing Address - Phone:509-452-1004
Mailing Address - Fax:509-452-1004
Practice Address - Street 1:611 W A ST
Practice Address - Street 2:
Practice Address - City:YAKIMA
Practice Address - State:WA
Practice Address - Zip Code:98902-2605
Practice Address - Country:US
Practice Address - Phone:509-452-1000
Practice Address - Fax:509-452-1004
Is Sole Proprietor?:No
Enumeration Date:2019-10-25
Last Update Date:2019-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACP00000171101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)