Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1041C0700X | Clinical Social Worker | 0904003979 | VA |
NPI | 1003093915 |
---|---|
Provider Name | Ms. Janie M. Mantooth |
First Address | Bedford, VA 24523-0628 |
Second Address | Bedford, VA 24523-6635 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 23/01/2008 |
Last Update Date | 02/10/2008 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
010219779 | (05) | VA |
010219779 | VIRGINIA PREMIER (01) | |
183482 | ANTHEM (01) | |
233212 | COMPSYCH CORP (01) | |
338400 | VALUE OPTIONS (01) | |
7664336 | AETNA (01) |