Basic Information
| Provider Information | |||||||||
| NPI: | 1528513728 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BLANTON | ||||||||
| FirstName: | MANDY | ||||||||
| MiddleName: | A | ||||||||
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| Mailing Information | |||||||||
| Address1: | 204 COOK RD | ||||||||
| Address2: | SUTIE 400 | ||||||||
| City: | LEBANON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 450369600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5132287800 | ||||||||
| FaxNumber: | 5136952952 | ||||||||
| Practice Location | |||||||||
| Address1: | 975 KINGSIVEW DRIVE | ||||||||
| Address2: | BLDG B | ||||||||
| City: | LEBANON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 450369562 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5132287800 | ||||||||
| FaxNumber: | 5132287857 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/18/2016 | ||||||||
| LastUpdateDate: | 08/18/2016 | ||||||||
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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 | 171M00000X | Y | Other Service Providers | Case Manager/Care Coordinator |
No ID Information.