Basic Information
| Provider Information | |||||||||
| NPI: | 1174829469 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MANDATO | ||||||||
| FirstName: | STACY | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MSSA, LSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 932909 | ||||||||
| Address2: | |||||||||
| City: | CLEVELAND | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441932909 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3308251152 | ||||||||
| FaxNumber: | 3308540829 | ||||||||
| Practice Location | |||||||||
| Address1: | 1302 W MAIN ST STE A | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 446411114 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3308755544 | ||||||||
| FaxNumber: | 3308758150 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/03/2011 | ||||||||
| LastUpdateDate: | 03/28/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/28/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | S1000364 | OH | N | Behavioral Health & Social Service Providers | Counselor | 1041C0700X | I.1801296-SUPV | OH | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 2069738 | 05 | OH | MEDICAID |