Provider Demographics
NPI:1528135779
Name:MANDICH, KATHRYN E
Entity type:Individual
Prefix:
First Name:KATHRYN
Middle Name:E
Last Name:MANDICH
Suffix:
Gender:F
Credentials:
Other - Prefix:DR
Other - First Name:KATHRYN
Other - Middle Name:E
Other - Last Name:VAN DAM
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DC
Mailing Address - Street 1:PO BOX 114
Mailing Address - Street 2:20 WALLKILL AVE
Mailing Address - City:WALLKILL
Mailing Address - State:NY
Mailing Address - Zip Code:12589-0114
Mailing Address - Country:US
Mailing Address - Phone:845-895-1131
Mailing Address - Fax:845-895-3243
Practice Address - Street 1:20 WALLKILL AVENUE
Practice Address - Street 2:
Practice Address - City:WALLKILL
Practice Address - State:NY
Practice Address - Zip Code:12589-0114
Practice Address - Country:US
Practice Address - Phone:845-895-1131
Practice Address - Fax:845-895-3243
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-30
Last Update Date:2017-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX008476111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYX86891Medicare PIN