Provider Demographics
NPI:1174653521
Name:MANDIS, MARY AXEL (EDD)
Entity type:Individual
Prefix:DR
First Name:MARY
Middle Name:AXEL
Last Name:MANDIS
Suffix:
Gender:F
Credentials:EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 HORIZON ROAD
Mailing Address - Street 2:414
Mailing Address - City:FT. LEE
Mailing Address - State:NJ
Mailing Address - Zip Code:07024
Mailing Address - Country:US
Mailing Address - Phone:212-769-9309
Mailing Address - Fax:
Practice Address - Street 1:241 CPW
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10024
Practice Address - Country:US
Practice Address - Phone:212-769-9309
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY06000578106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist