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General NPI Number Information
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NPI Number | 1316040256
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Entity Type | Individual
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Provider Name | GEORGE MICHAEL MANTAS L.L.P.
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Gender | Male
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Dates
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Enumeration Date | 09/06/2006
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Last Update Date | 09/11/2008
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Provider Practice Location Address
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Address Line | 1001 MILITARY ST
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City | PORT HURON
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State | MI
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Zip | 48060-5416
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Country | US
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Telephone | 810-985-5168
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Fax | 810-985-9011
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Provider Business Mailing Address
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Address Line | 5360 SMITHS CREEK RD
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City | KIMBALL
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State | MI
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Zip | 48074-3807
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 6301010808
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License Number State | MI
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Taxonomy #2
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Taxonomy Code | 103TA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Psychologist
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License Number | 6301010808
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License Number State | MI
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