Provider Demographics
NPI:1609868439
Name:MANTILLA, MARY AGNES (LCSW)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:AGNES
Last Name:MANTILLA
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:A
Other - Last Name:TOR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3 NEPTUNE RD STE A18F
Mailing Address - Street 2:
Mailing Address - City:POUGHKEEPSIE
Mailing Address - State:NY
Mailing Address - Zip Code:12601-5500
Mailing Address - Country:US
Mailing Address - Phone:845-549-8223
Mailing Address - Fax:
Practice Address - Street 1:3 NEPTUNE RD STE A18F
Practice Address - Street 2:
Practice Address - City:POUGHKEEPSIE
Practice Address - State:NY
Practice Address - Zip Code:12601-5500
Practice Address - Country:US
Practice Address - Phone:845-549-8223
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-18
Last Update Date:2017-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY068980-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY068980-1OtherLMSW LICENSE