Provider Demographics
NPI:1194133082
Name:MANDERS, LORA JEANETTE (MA, LLPC, CAADC, PAC)
Entity type:Individual
Prefix:MRS
First Name:LORA
Middle Name:JEANETTE
Last Name:MANDERS
Suffix:
Gender:F
Credentials:MA, LLPC, CAADC, PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6869 S OCCIDENTAL RD
Mailing Address - Street 2:
Mailing Address - City:TECUMSEH
Mailing Address - State:MI
Mailing Address - Zip Code:49286-9784
Mailing Address - Country:US
Mailing Address - Phone:517-423-4777
Mailing Address - Fax:517-423-7257
Practice Address - Street 1:6869 S OCCIDENTAL RD
Practice Address - Street 2:
Practice Address - City:TECUMSEH
Practice Address - State:MI
Practice Address - Zip Code:49286-9784
Practice Address - Country:US
Practice Address - Phone:517-423-4777
Practice Address - Fax:517-423-7257
Is Sole Proprietor?:No
Enumeration Date:2014-07-24
Last Update Date:2019-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIC-02189101YA0400X
MI6401010851101YM0800X
MI5601008012363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1194133082Medicaid
MIM35150147OtherMEDICARE PTAN