MEDICARE: MRS. STEFANIE MANTALVANOS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103K00000X	Behavior Analyst

General Provider Information

NPI Number	:	1285887349
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. STEFANIE MANTALVANOS

Provider Business Mailing Address
First Line	:	3136 48TH ST
Second Line	:
City	:	ASTORIA
State	:	NY
Zip	:	11103-1632
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3711 35TH AVE
Second Line	:
City	:	ASTORIA
State	:	NY
Zip	:	11101-1441
Country	:	US
Telephone Number	:	718-706-7500
Fax Number	:	718-706-9595

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/02/2008
Last Update Date	:	11/02/2008

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