Basic Information
| Provider Information | |||||||||
| NPI: | 1396752655 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MANTHEY | ||||||||
| FirstName: | ELSA | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | LPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1049 N LYNNDALE DR | ||||||||
| Address2: | SUITE 1B | ||||||||
| City: | APPLETON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 549143050 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9207319798 | ||||||||
| FaxNumber: | 9207311097 | ||||||||
| Practice Location | |||||||||
| Address1: | 1049 N LYNNDALE DR | ||||||||
| Address2: | SUITE 1B | ||||||||
| City: | APPLETON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 549143050 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9207319798 | ||||||||
| FaxNumber: | 9207311097 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/01/2006 | ||||||||
| LastUpdateDate: | 10/09/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 2726-125 | WI | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | 39792800 | 05 | WI | MEDICAID |