Healthcare Provider Details

I. General information

NPI: 1184188427
Provider Name (Legal Business Name): MANDY WALLENFELSZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/30/2019
Last Update Date: 02/19/2024
Certification Date: 02/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

517 3RD AVE
CHESAPEAKE OH
45619-1036
US

IV. Provider business mailing address

81 TOWNSHIP ROAD 349
IRONTON OH
45638-8617
US

V. Phone/Fax

Practice location:
  • Phone: 740-451-1455
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCDCA.179510
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: