Provider Demographics
NPI:1295497832
Name:MANTALAS, TAMMY LEE
Entity type:Individual
Prefix:
First Name:TAMMY
Middle Name:LEE
Last Name:MANTALAS
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 1:1928 PROCTOR AVE
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32817-4200
Mailing Address - Country:US
Mailing Address - Phone:407-236-4471
Mailing Address - Fax:
Practice Address - Street 1:1928 PROCTOR AVE
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32817-4200
Practice Address - Country:US
Practice Address - Phone:407-236-4471
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-12
Last Update Date:2021-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLIMH18347101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health