Provider Demographics
NPI:1285272559
Name:MANDELLA, MICHAEL ANTHONY (MA LIC 99)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:ANTHONY
Last Name:MANDELLA
Suffix:
Gender:M
Credentials:MA LIC 99
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:615 RESERVOIR RD
Mailing Address - Street 2:
Mailing Address - City:LUNENBURG
Mailing Address - State:MA
Mailing Address - Zip Code:01462-1540
Mailing Address - Country:US
Mailing Address - Phone:978-771-7582
Mailing Address - Fax:978-582-8264
Practice Address - Street 1:615 RESERVOIR RD
Practice Address - Street 2:
Practice Address - City:LUNENBURG
Practice Address - State:MA
Practice Address - Zip Code:01462-1540
Practice Address - Country:US
Practice Address - Phone:978-771-7582
Practice Address - Fax:978-582-8264
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-17
Last Update Date:2019-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAMA99174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty