Provider Demographics
NPI:1811928559
Name:MANTELL, MICHAEL R (PHD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:R
Last Name:MANTELL
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
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Mailing Address - Street 1:5565 GROSSMONT CENTER DR
Mailing Address - Street 2:BUILDING 1, SUITE 223
Mailing Address - City:LA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:91942-3020
Mailing Address - Country:US
Mailing Address - Phone:619-644-1111
Mailing Address - Fax:619-644-1115
Practice Address - Street 1:5565 GROSSMONT CENTER DR
Practice Address - Street 2:BUILDING 1, SUITE 223
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91942-3020
Practice Address - Country:US
Practice Address - Phone:619-644-1111
Practice Address - Fax:619-644-1115
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-05
Last Update Date:2011-02-04
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAPSY 5020103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA2436992OtherAETNA
CA2436992OtherAETNA