Provider Demographics
NPI:1104603422
Name:MANTHA, GAYATRI SNEH (PSYD)
Entity type:Individual
Prefix:DR
First Name:GAYATRI
Middle Name:SNEH
Last Name:MANTHA
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2700 JETSTREAM RD
Mailing Address - Street 2:
Mailing Address - City:HERNDON
Mailing Address - State:VA
Mailing Address - Zip Code:20171-2576
Mailing Address - Country:US
Mailing Address - Phone:703-554-5246
Mailing Address - Fax:
Practice Address - Street 1:24600 MILLSTREAM DR STE 340
Practice Address - Street 2:
Practice Address - City:STONE RIDGE
Practice Address - State:VA
Practice Address - Zip Code:20105-5686
Practice Address - Country:US
Practice Address - Phone:703-327-0335
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-11
Last Update Date:2023-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103TC2200X
VA0805002487103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent