Healthcare Provider Details

I. General information

NPI: 1174829469
Provider Name (Legal Business Name): STACY M MANDATO MSSA, LSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/03/2011
Last Update Date: 03/28/2022
Certification Date: 03/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1302 W MAIN ST STE A
LOUISVILLE OH
44641-1114
US

IV. Provider business mailing address

PO BOX 932909
CLEVELAND OH
44193-2909
US

V. Phone/Fax

Practice location:
  • Phone: 330-875-5544
  • Fax: 330-875-8150
Mailing address:
  • Phone: 330-825-1152
  • Fax: 330-854-0829

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberS1000364
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI.1801296-SUPV
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: