Provider Demographics
NPI:1831640895
Name:MANTICA, LEEANNA
Entity Type:Individual
Prefix:
First Name:LEEANNA
Middle Name:
Last Name:MANTICA
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 1:10841 HIGHLAND AVE
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33966-1124
Mailing Address - Country:US
Mailing Address - Phone:904-612-6951
Mailing Address - Fax:
Practice Address - Street 1:3820 COLONIAL BLVD
Practice Address - Street 2:SUITE 102
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33966-1094
Practice Address - Country:US
Practice Address - Phone:239-208-9449
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-14
Last Update Date:2016-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLIMH 13942101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health