Basic Information
| Provider Information | |||||||||
| NPI: | 1326341710 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MANTIS | ||||||||
| FirstName: | HAYLEY | ||||||||
| MiddleName: | ELIZABETH | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | COTA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 215 E 37TH AVE APT 1 | ||||||||
| Address2: | |||||||||
| City: | GRIFFITH | ||||||||
| State: | IN | ||||||||
| PostalCode: | 463191157 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2195139629 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3703 W LAKE AVE | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | GLENVIEW | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600261223 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8479981188 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/07/2010 | ||||||||
| LastUpdateDate: | 12/07/2010 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 224Z00000X | 057.003320 | IL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapy Assistant |
No ID Information.