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General NPI Number Information
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NPI Number | 1508099698
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Entity Type | Individual
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Provider Name | MICHAEL JOHN MANDLI PH.D.
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Gender | Male
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Dates
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Enumeration Date | 08/24/2009
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Last Update Date | 08/24/2009
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Provider Practice Location Address
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Address Line | 10265 WEST NORTH AVE SUITE 103
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City | WAUWATOSA
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State | WI
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Zip | 53226
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Country | US
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Telephone | 414-617-2656
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Fax |
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Provider Business Mailing Address
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Address Line | W158N10263 MOHAWK DR
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City | GERMANTOWN
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State | WI
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Zip | 53022-4853
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Country | US
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Telephone | 414-617-2656
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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 | 103T00000X
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Taxonomy Name | Psychologist
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License Number | 1445-057
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License Number State | WI
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