Healthcare Provider Details

I. General information

NPI: 1609383801
Provider Name (Legal Business Name): MARY ANDAHL MANTELL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/09/2018
Last Update Date: 06/16/2026
Certification Date: 06/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4940 O ST
LINCOLN NE
68510-1957
US

IV. Provider business mailing address

6032 PINE ST
OMAHA NE
68106-2118
US

V. Phone/Fax

Practice location:
  • Phone: 402-880-0420
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number6483
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: