Provider Demographics
NPI:1528703972
Name:MANDELL, MARK (LPC, NCC, MED)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:MANDELL
Suffix:
Gender:M
Credentials:LPC, NCC, MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:232 VANCE RD STE 202B
Mailing Address - Street 2:
Mailing Address - City:VALLEY PARK
Mailing Address - State:MO
Mailing Address - Zip Code:63088-1575
Mailing Address - Country:US
Mailing Address - Phone:636-489-9575
Mailing Address - Fax:
Practice Address - Street 1:232 VANCE RD STE 202B
Practice Address - Street 2:
Practice Address - City:VALLEY PARK
Practice Address - State:MO
Practice Address - Zip Code:63088-1575
Practice Address - Country:US
Practice Address - Phone:636-489-9575
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-30
Last Update Date:2022-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2019006481101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional