Provider Demographics
NPI:1174829469
Name:MANDATO, STACY M (MSSA, LSW)
Entity Type:Individual
Prefix:MS
First Name:STACY
Middle Name:M
Last Name:MANDATO
Suffix:
Gender:F
Credentials:MSSA, LSW
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 932909
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44193-2909
Mailing Address - Country:US
Mailing Address - Phone:330-825-1152
Mailing Address - Fax:330-854-0829
Practice Address - Street 1:1302 W MAIN ST STE A
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:OH
Practice Address - Zip Code:44641-1114
Practice Address - Country:US
Practice Address - Phone:330-875-5544
Practice Address - Fax:330-875-8150
Is Sole Proprietor?:No
Enumeration Date:2011-02-03
Last Update Date:2022-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS1000364101Y00000X
OHI.1801296-SUPV1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2069738Medicaid