Provider Demographics
NPI:1386144624
Name:MANTA, OLIVIA LAUREN
Entity type:Individual
Prefix:MRS
First Name:OLIVIA
Middle Name:LAUREN
Last Name:MANTA
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:OLIVIA
Other - Middle Name:LAUREN
Other - Last Name:ECCLESTONE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:44670 ANN ARBOR RD W STE 130
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MI
Mailing Address - Zip Code:48170-4085
Mailing Address - Country:US
Mailing Address - Phone:313-278-4601
Mailing Address - Fax:
Practice Address - Street 1:38935 ANN ARBOR RD
Practice Address - Street 2:
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48150-3397
Practice Address - Country:US
Practice Address - Phone:248-886-9540
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-13
Last Update Date:2025-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst