Provider Demographics
NPI:1659852093
Name:ROBERT MANTELL, RN, PHD, LICENSED PSYCHOLOGIST
Entity Type:Organization
Organization Name:ROBERT MANTELL, RN, PHD, LICENSED PSYCHOLOGIST
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:MANTELL
Authorized Official - Suffix:
Authorized Official - Credentials:RN, PHD
Authorized Official - Phone:651-503-6322
Mailing Address - Street 1:1549 BRANSTON ST
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55108-1437
Mailing Address - Country:US
Mailing Address - Phone:651-503-6322
Mailing Address - Fax:
Practice Address - Street 1:821 RAYMOND AVE STE 330
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55114-1510
Practice Address - Country:US
Practice Address - Phone:651-503-6322
Practice Address - Fax:651-642-1506
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-23
Last Update Date:2018-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP4396103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounselingGroup - Single Specialty