=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063296754
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MANDALA FAMILY WELLNESS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/23/2023
-----------------------------------------------------
Last Update Date | 08/23/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 171 CANAL BLVD
-----------------------------------------------------
City | PONTE VEDRA BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32082-3607
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-834-7581
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 171 CANAL BLVD
-----------------------------------------------------
City | PONTE VEDRA BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32082-3607
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR OF OPERATIONS AND COMPLIAN
-----------------------------------------------------
Name | MATTHEW DELANEY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 904-373-0082
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 235Z00000X
-----------------------------------------------------
Taxonomy Name | Speech-Language Pathologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 225X00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------