Provider Demographics
NPI:1073034120
Name:MANDELL, LYDIA NICOLE (LMT)
Entity Type:Individual
Prefix:
First Name:LYDIA
Middle Name:NICOLE
Last Name:MANDELL
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:728 S 4TH ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19147-3120
Mailing Address - Country:US
Mailing Address - Phone:215-280-3823
Mailing Address - Fax:
Practice Address - Street 1:728 S 4TH ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19147-3120
Practice Address - Country:US
Practice Address - Phone:215-922-3235
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-29
Last Update Date:2017-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMSG011032225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist