MEDICARE: PAMELA MANDT LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	58831	TX

General Provider Information

NPI Number	:	1922617166
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PAMELA MANDT LCSW

Provider Business Mailing Address
First Line	:	4312 POTOMAC AVE
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75205-2629
Country	:	US
Telephone Number	:	214-458-0113
Fax Number	:

Provider Business Practice Location Address
First Line	:	4312 POTOMAC AVE
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75205-2629
Country	:	US
Telephone Number	:	214-458-0113
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/23/2020
Last Update Date	:	07/23/2020

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