Provider Demographics
NPI:1124727763
Name:MANDEVILLE, COURTNEY ELLEN
Entity type:Individual
Prefix:
First Name:COURTNEY
Middle Name:ELLEN
Last Name:MANDEVILLE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6694 WINBARR WAY
Mailing Address - Street 2:
Mailing Address - City:CANAL WINCHESTER
Mailing Address - State:OH
Mailing Address - Zip Code:43110-8730
Mailing Address - Country:US
Mailing Address - Phone:614-972-3420
Mailing Address - Fax:
Practice Address - Street 1:3121 W BROAD ST
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43204-1306
Practice Address - Country:US
Practice Address - Phone:614-869-2002
Practice Address - Fax:614-792-6240
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-02
Last Update Date:2023-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCDCA.182294101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)