Basic Information
Provider Information | |||||||||
NPI: | 1598081499 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MANDREKY | ||||||||
FirstName: | EVE | ||||||||
MiddleName: | ROSE | ||||||||
NamePrefix: | MS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MA, LPC | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | MANDREKY | ||||||||
OtherFirstName: | EVE | ||||||||
OtherMiddleName: | ROSE | ||||||||
OtherNamePrefix: | MS. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | CADC | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 2110 E HILL RD APT 23 | ||||||||
Address2: |   | ||||||||
City: | GRAND BLANC | ||||||||
State: | MI | ||||||||
PostalCode: | 484395106 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8107714876 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 901 CHIPPEWA ST | ||||||||
Address2: |   | ||||||||
City: | FLINT | ||||||||
State: | MI | ||||||||
PostalCode: | 485031552 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8102329950 | ||||||||
FaxNumber: | 8102327599 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/16/2010 | ||||||||
LastUpdateDate: | 12/05/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X |   |   | N |   | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YM0800X |   |   | Y |   | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.