Healthcare Provider Details

I. General information

NPI: 1619458676
Provider Name (Legal Business Name): JOSE OSCAR MANTILLA-RIVAS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/27/2018
Last Update Date: 05/18/2023
Certification Date: 05/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4 ALLEGHENY CTR FL 8
PITTSBURGH PA
15212-5255
US

IV. Provider business mailing address

4 ALLEGHENY CTR FL 8
PITTSBURGH PA
15212-5255
US

V. Phone/Fax

Practice location:
  • Phone: 412-330-4000
  • Fax: 412-330-4366
Mailing address:
  • Phone: 412-330-4000
  • Fax: 412-330-4366

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberPC009876
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberMT215100
License Number StatePA
# 3
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberMD477620
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: