Provider Demographics
NPI:1780038034
Name:MANTEY, DESIREE NICOLE
Entity Type:Individual
Prefix:
First Name:DESIREE
Middle Name:NICOLE
Last Name:MANTEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2145 CENTENNIAL PLZ
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97401-2421
Mailing Address - Country:US
Mailing Address - Phone:541-543-0037
Mailing Address - Fax:
Practice Address - Street 1:2145 CENTENNIAL PLZ
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401-2421
Practice Address - Country:US
Practice Address - Phone:541-543-0037
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-22
Last Update Date:2016-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORA102722101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health