Healthcare Provider Details

I. General information

NPI: 1679882880
Provider Name (Legal Business Name): DOROTHY MARIE MANDEL PSYCHOLOGY LICENSE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/05/2010
Last Update Date: 02/20/2020
Certification Date: 02/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1144 SONOMA AVE STE 117
SANTA ROSA CA
95405-4812
US

IV. Provider business mailing address

1144 SONOMA AVE STE 117
SANTA ROSA CA
95405-4812
US

V. Phone/Fax

Practice location:
  • Phone: 707-322-3222
  • Fax: 707-526-1913
Mailing address:
  • Phone: 707-322-3222
  • Fax: 707-526-1913

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TA0400X
TaxonomyAddiction (Substance Use Disorder) Psychologist
License NumberPSY23697
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License NumberPSY23697
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY23697
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License NumberPSY23697
License Number StateCA
# 5
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License NumberPSY23697
License Number StateCA
# 6
Primary TaxonomyN
Taxonomy Code103TF0000X
TaxonomyFamily Psychologist
License NumberPSY23697
License Number StateCA
# 7
Primary TaxonomyN
Taxonomy Code103TH0004X
TaxonomyHealth Psychologist
License NumberPSY23697
License Number StateCA
# 8
Primary TaxonomyN
Taxonomy Code103TM1800X
TaxonomyIntellectual & Developmental Disabilities Psychologist
License NumberPSY23697
License Number StateCA
# 9
Primary TaxonomyY
Taxonomy Code103TA0700X
TaxonomyAdult Development & Aging Psychologist
License NumberPSY23697
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: