Provider Demographics
NPI:1356351118
Name:MANTEL, KEITH HOWARD (LICSW)
Entity type:Individual
Prefix:MR
First Name:KEITH
Middle Name:HOWARD
Last Name:MANTEL
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:409 W BROADWAY
Mailing Address - Street 2:
Mailing Address - City:SOUTH BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02127-2245
Mailing Address - Country:US
Mailing Address - Phone:617-269-7500
Mailing Address - Fax:
Practice Address - Street 1:409 W BROADWAY
Practice Address - Street 2:
Practice Address - City:SOUTH BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02127-2245
Practice Address - Country:US
Practice Address - Phone:617-269-7500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2018-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1177381041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical