Provider Demographics
NPI:1578372397
Name:MANTILLA NAVAS, JUAN SEBASTIAN (LGPC)
Entity type:Individual
Prefix:
First Name:JUAN
Middle Name:SEBASTIAN
Last Name:MANTILLA NAVAS
Suffix:
Gender:M
Credentials:LGPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6508 DEER POINTE DR STE 4
Mailing Address - Street 2:
Mailing Address - City:SALISBURY
Mailing Address - State:MD
Mailing Address - Zip Code:21804-1668
Mailing Address - Country:US
Mailing Address - Phone:410-742-6016
Mailing Address - Fax:
Practice Address - Street 1:6508 DEER POINTE DR STE 4
Practice Address - Street 2:
Practice Address - City:SALISBURY
Practice Address - State:MD
Practice Address - Zip Code:21804-1668
Practice Address - Country:US
Practice Address - Phone:410-742-6016
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-06
Last Update Date:2025-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLGP15863101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional