Healthcare Provider Details

I. General information

NPI: 1922164383
Provider Name (Legal Business Name): MANDALA PSYCHOLOGICAL SERVICES, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/29/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2785 W 5TH ST APT 10E
BROOKLYN NY
11224-4612
US

IV. Provider business mailing address

2785 W 5TH ST APT 10E
BROOKLYN NY
11224-4612
US

V. Phone/Fax

Practice location:
  • Phone: 646-415-1915
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number016210
License Number StateNY

VIII. Authorized Official

Name: YELENA RAZDOLSKAYA
Title or Position: PSYCHOLOGIST
Credential: PSY.D
Phone: 646-415-1915