Basic Information
Provider Information | |||||||||
NPI: | 1447878947 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MANTOVANI | ||||||||
FirstName: | CELIA | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | LCPC | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 901 WASHINGTON AVE STE 100 | ||||||||
Address2: |   | ||||||||
City: | PORTLAND | ||||||||
State: | ME | ||||||||
PostalCode: | 041032842 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2078711200 | ||||||||
FaxNumber: | 2078711232 | ||||||||
Practice Location | |||||||||
Address1: | 901 WASHINGTON AVE STE 100 | ||||||||
Address2: |   | ||||||||
City: | PORTLAND | ||||||||
State: | ME | ||||||||
PostalCode: | 041032842 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2078711200 | ||||||||
FaxNumber: | 2078711232 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/10/2020 | ||||||||
LastUpdateDate: | 07/28/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 07/28/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | 4301502838 | MI | N |   | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 101YP2500X | CC5637 | ME | Y |   | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
ID | Type | State | Issuer | Description | 14919161 | 01 |   | CAHQ | OTHER | 4301502838 | 01 | MI | MD LICENSE | OTHER |