1538255989 NPI number — MS. MADELEINE T MANDELBAUM MSW, LICSW

Table of content: MS. MADELEINE T MANDELBAUM MSW, LICSW (NPI 1538255989)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1538255989 NPI number — MS. MADELEINE T MANDELBAUM MSW, LICSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MANDELBAUM
Provider First Name:
MADELEINE
Provider Middle Name:
T
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
MSW, LICSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1538255989
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/09/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
17 QUENTIN DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LONDONDERRY
Provider Business Mailing Address State Name:
NH
Provider Business Mailing Address Postal Code:
03053-6124
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
603-432-0067
Provider Business Mailing Address Fax Number:
603-437-2665

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12 PARMENTER RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LONDONDERRY
Provider Business Practice Location Address State Name:
NH
Provider Business Practice Location Address Postal Code:
03053-3280
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
603-437-2069
Provider Business Practice Location Address Fax Number:
603-437-5588
Provider Enumeration Date:
10/05/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  275 , registered in the state of NH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 1041C0700X , with the licence number: 106128 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 11258581 . This is a "AETNA" identifier , issued by the state of ( NH ) . This identifiers is of the category "OTHER".
  • Identifier: 30007950 , issued by the state of ( NH ) . This identifiers is of the category "MEDICAID".
  • Identifier: NA1394 . This is a "HARVARD PILGRIM" identifier , issued by the state of ( NH ) . This identifiers is of the category "OTHER".
  • Identifier: P06776 . This is a "BC/BS MA" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 006037 . This is a "HPHC-VALUE OPTIONS" identifier , issued by the state of ( NH ) . This identifiers is of the category "OTHER".
  • Identifier: 65429 . This is a "UNITED BEHAVIORAL HEALTH" identifier , issued by the state of ( NH ) . This identifiers is of the category "OTHER".
  • Identifier: MAN683192 . This is a "ANTHEM BC/BS NH" identifier , issued by the state of ( NH ) . This identifiers is of the category "OTHER".
  • Identifier: 000275 . This is a "TUFTS HEALTH PLAN" identifier , issued by the state of ( NH ) . This identifiers is of the category "OTHER".




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