1013530229 NPI number — ELYCE DARCELL MANDICH MSW, LCSW, PPSC

Table of content: (NPI 1588839989)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013530229 NPI number — ELYCE DARCELL MANDICH MSW, LCSW, PPSC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MANDICH
Provider First Name:
ELYCE
Provider Middle Name:
DARCELL
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MSW, LCSW, PPSC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MAXWELL
Provider Other First Name:
ELYCE
Provider Other Middle Name:
DARCELL
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MSW, LCSW, PPSC
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1013530229
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/21/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
31350 RANCHO VISTA RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TEMECULA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92592-6200
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
951-401-0533
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
27215 NICOLAS RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TEMECULA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92591-7348
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
951-401-0533
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/21/2020

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:  831141 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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