Healthcare Provider Details

I. General information

NPI: 1649140112
Provider Name (Legal Business Name): KRISTOPHER MANDY PSYD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/10/2025
Last Update Date: 03/24/2026
Certification Date: 03/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4347 SECURITY PKWY
NEW ALBANY IN
47150-9374
US

IV. Provider business mailing address

4347 SECURITY PKWY
NEW ALBANY IN
47150-9374
US

V. Phone/Fax

Practice location:
  • Phone: 502-287-4000
  • Fax:
Mailing address:
  • Phone: 502-287-4100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TA0400X
TaxonomyAddiction (Substance Use Disorder) Psychologist
License Number20044062A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number20044062A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: