Provider Demographics
NPI:1760665236
Name:MANTICA, SARAH JANE (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:SARAH
Middle Name:JANE
Last Name:MANTICA
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:45 ROCK RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:CHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:10918-2507
Mailing Address - Country:US
Mailing Address - Phone:845-240-4536
Mailing Address - Fax:
Practice Address - Street 1:45 ROCK RIDGE RD
Practice Address - Street 2:
Practice Address - City:CHESTER
Practice Address - State:NY
Practice Address - Zip Code:10918-2507
Practice Address - Country:US
Practice Address - Phone:845-240-4536
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-07
Last Update Date:2016-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY079206-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYA300139699Medicare PIN