=====================================================
General NPI Number Information
=====================================================
NPI Number | 1023224623
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ETHAN C MANDELKERN
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/14/2007
-----------------------------------------------------
Last Update Date | 08/12/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 419 CHESTNUT ST SUITE #2
-----------------------------------------------------
City | MOUNT SHASTA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 96067-2918
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 530-918-8348
-----------------------------------------------------
Fax | 530-918-5477
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 419 CHESTNUT ST SUITE #2
-----------------------------------------------------
City | MOUNT SHASTA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 96067-2918
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 530-918-8348
-----------------------------------------------------
Fax | 530-918-5477
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | LPCC726
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | LCSW64679
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------