Healthcare Provider Details

I. General information

NPI: 1548011695
Provider Name (Legal Business Name): JORDAN MANDIC OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/28/2024
Last Update Date: 09/14/2026
Certification Date: 09/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2001 NYS ROUTE 17M
GOSHEN NY
10924
US

IV. Provider business mailing address

25 BIGERT DR
NEW HAMPTON NY
10958-4320
US

V. Phone/Fax

Practice location:
  • Phone: 845-458-8661
  • Fax:
Mailing address:
  • Phone: 845-662-4261
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number029007
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: