Provider Demographics
NPI:1366597676
Name:MANTELMAN, ANDREW GENE (PSYD)
Entity type:Individual
Prefix:DR
First Name:ANDREW
Middle Name:GENE
Last Name:MANTELMAN
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:704 PINTAIL CT
Mailing Address - Street 2:
Mailing Address - City:DEERFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60015-3645
Mailing Address - Country:US
Mailing Address - Phone:847-219-9600
Mailing Address - Fax:
Practice Address - Street 1:704 PINTAIL CT
Practice Address - Street 2:
Practice Address - City:DEERFIELD
Practice Address - State:IL
Practice Address - Zip Code:60015-3645
Practice Address - Country:US
Practice Address - Phone:847-219-9600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL04926447OtherBCBS
IL585090Medicare ID - Type Unspecified