Provider Demographics
NPI:1104360932
Name:LAW, MANDY
Entity Type:Individual
Prefix:
First Name:MANDY
Middle Name:
Last Name:LAW
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1662
Mailing Address - Street 2:
Mailing Address - City:MONTEREY PARK
Mailing Address - State:CA
Mailing Address - Zip Code:91754-8662
Mailing Address - Country:US
Mailing Address - Phone:209-651-0243
Mailing Address - Fax:
Practice Address - Street 1:2677 N MAIN ST STE 130
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92705-6665
Practice Address - Country:US
Practice Address - Phone:714-274-7577
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-13
Last Update Date:2023-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF96790106H00000X
VA0717001972106H00000X
TX204890106H00000X
CALMFT116069106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist