Provider Demographics
NPI:1639711641
Name:MANTY, MEGAN JEAN (MS, LPCC)
Entity Type:Individual
Prefix:MRS
First Name:MEGAN
Middle Name:JEAN
Last Name:MANTY
Suffix:
Gender:F
Credentials:MS, LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12400 PORTLAND AVE STE 130
Mailing Address - Street 2:
Mailing Address - City:BURNSVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55337-6839
Mailing Address - Country:US
Mailing Address - Phone:763-607-7817
Mailing Address - Fax:612-662-8779
Practice Address - Street 1:12400 PORTLAND AVE STE 130
Practice Address - Street 2:
Practice Address - City:BURNSVILLE
Practice Address - State:MN
Practice Address - Zip Code:55337-6839
Practice Address - Country:US
Practice Address - Phone:763-607-7817
Practice Address - Fax:612-662-8779
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-10
Last Update Date:2023-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2260101YP2500X
MN02260101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional