Healthcare Provider Details

I. General information

NPI: 1316634892
Provider Name (Legal Business Name): MANDIE ESPINO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/24/2023
Last Update Date: 04/24/2023
Certification Date: 04/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

563 PACHMAN CIR
LEHIGH ACRES FL
33974-9483
US

IV. Provider business mailing address

563 PACHMAN CIR
LEHIGH ACRES FL
33974-9483
US

V. Phone/Fax

Practice location:
  • Phone: 239-839-2983
  • Fax: 239-320-5117
Mailing address:
  • Phone: 239-839-2983
  • Fax: 239-320-5117

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: