Healthcare Provider Details

I. General information

NPI: 1538255989
Provider Name (Legal Business Name): MADELEINE T MANDELBAUM MSW, LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/05/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12 PARMENTER RD
LONDONDERRY NH
03053-3280
US

IV. Provider business mailing address

17 QUENTIN DR
LONDONDERRY NH
03053-6124
US

V. Phone/Fax

Practice location:
  • Phone: 603-437-2069
  • Fax: 603-437-5588
Mailing address:
  • Phone: 603-432-0067
  • Fax: 603-437-2665

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number275
License Number StateNH
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number106128
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: