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General NPI Number Information
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NPI Number | 1497314504
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Entity Type | Individual
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Provider Name | CHARLOT MARIE MANDERSON
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Gender | Female
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Dates
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Enumeration Date | 06/12/2019
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Last Update Date | 07/11/2019
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Provider Practice Location Address
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Address Line | 1002 S DILLARD ST
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City | WINTER GARDEN
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State | FL
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Zip | 34787-3991
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Country | US
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Telephone | 407-877-0029
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Fax | 407-358-5207
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Provider Business Mailing Address
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Address Line | 3507 STARCATCHER ST
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City | SAINT CLOUD
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State | FL
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Zip | 34772-8272
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Country | US
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Telephone | 407-508-4444
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 252Y00000X
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Taxonomy Name | Early Intervention Provider Agency
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License Number |
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License Number State |
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