Provider Demographics
NPI:1588082697
Name:ADAMS, MANDY
Entity type:Individual
Prefix:
First Name:MANDY
Middle Name:
Last Name:ADAMS
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 1:1236 HIGHWAY J
Mailing Address - Street 2:
Mailing Address - City:NEW FLORENCE
Mailing Address - State:MO
Mailing Address - Zip Code:63363-3007
Mailing Address - Country:US
Mailing Address - Phone:314-504-3828
Mailing Address - Fax:636-458-6101
Practice Address - Street 1:343 S KIRKWOOD RD
Practice Address - Street 2:BOX 220081
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63122-4015
Practice Address - Country:US
Practice Address - Phone:314-504-3828
Practice Address - Fax:636-458-6101
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-04
Last Update Date:2014-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20130411575101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health