Provider Demographics
NPI:1588962682
Name:MANDELBAUM, CAROLYN
Entity type:Individual
Prefix:
First Name:CAROLYN
Middle Name:
Last Name:MANDELBAUM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CAROLYN
Other - Middle Name:
Other - Last Name:KOCH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MS, CCC-SLP
Mailing Address - Street 1:143 BENNETT AVE
Mailing Address - Street 2:APT 6P
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10040-4019
Mailing Address - Country:US
Mailing Address - Phone:212-923-0076
Mailing Address - Fax:
Practice Address - Street 1:111 E 59TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10022-1202
Practice Address - Country:US
Practice Address - Phone:212-821-9605
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-03-14
Last Update Date:2011-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY014199235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist