Provider Demographics
NPI:1922082569
Name:MANDELLO, MARY J (PHD)
Entity type:Individual
Prefix:MS
First Name:MARY
Middle Name:J
Last Name:MANDELLO
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:401 N LINDBERGH BLVD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-7839
Mailing Address - Country:US
Mailing Address - Phone:314-997-1183
Mailing Address - Fax:314-997-1196
Practice Address - Street 1:401 N LINDBERGH BLVD
Practice Address - Street 2:SUITE 300
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-7839
Practice Address - Country:US
Practice Address - Phone:314-997-1183
Practice Address - Fax:314-997-1196
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MO00771103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
S25776Medicare UPIN