Provider Demographics
NPI:1831917608
Name:MANTKE, MARISSA
Entity type:Individual
Prefix:
First Name:MARISSA
Middle Name:
Last Name:MANTKE
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 1:5054 COOPERS LANDING DR APT 1C
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49004-6662
Mailing Address - Country:US
Mailing Address - Phone:517-219-3853
Mailing Address - Fax:517-938-5948
Practice Address - Street 1:119 BINGHAM DR
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:MI
Practice Address - Zip Code:49230-8926
Practice Address - Country:US
Practice Address - Phone:517-219-3853
Practice Address - Fax:517-438-5948
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-01
Last Update Date:2024-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68511188991041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty