Healthcare Provider Details

I. General information

NPI: 1912048059
Provider Name (Legal Business Name): MICHELLE MANDAP LVN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/10/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1724 E WASHINGTON BLVD
PASADENA CA
91104-2751
US

IV. Provider business mailing address

2131 CRAWFORD AVE
ALTADENA CA
91001-2429
US

V. Phone/Fax

Practice location:
  • Phone: 626-794-1161
  • Fax:
Mailing address:
  • Phone: 323-839-2981
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberVN193118
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: