Basic Information
| Provider Information | |||||||||
| NPI: | 1801451463 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CIACELLI-BROWN | ||||||||
| FirstName: | MANDI | ||||||||
| MiddleName: | MARIE | ||||||||
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| Credential: | LPN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 467 GODFROY AVE | ||||||||
| Address2: | |||||||||
| City: | MONROE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481622766 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7343442504 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3250 N MONROE ST | ||||||||
| Address2: | |||||||||
| City: | MONROE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481629297 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7343843402 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/08/2019 | ||||||||
| LastUpdateDate: | 05/08/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0405X | 4703095538 | MI | N | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation, Substance Use Disorder | 364SR0400X | 4703095538 | MI | N | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | Rehabilitation | 324500000X | 4703095538 | MI | Y | Residential Treatment Facilities | Substance Abuse Rehabilitation Facility |
No ID Information.