Healthcare Provider Details

I. General information

NPI: 1316040256
Provider Name (Legal Business Name): GEORGE MICHAEL MANTAS L.L.P.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/06/2006
Last Update Date: 09/11/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 MILITARY ST
PORT HURON MI
48060-5416
US

IV. Provider business mailing address

5360 SMITHS CREEK RD
KIMBALL MI
48074-3807
US

V. Phone/Fax

Practice location:
  • Phone: 810-985-5168
  • Fax: 810-985-9011
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number6301010808
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code103TA0400X
TaxonomyAddiction (Substance Use Disorder) Psychologist
License Number6301010808
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: