Provider Demographics
NPI:1205035540
Name:MANDELBAUM, ROBERT (CASAC)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:
Last Name:MANDELBAUM
Suffix:
Gender:M
Credentials:CASAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:151 PARKWOOD DR
Mailing Address - Street 2:
Mailing Address - City:SHIRLEY
Mailing Address - State:NY
Mailing Address - Zip Code:11967-3938
Mailing Address - Country:US
Mailing Address - Phone:631-543-6200
Mailing Address - Fax:
Practice Address - Street 1:151 PARKWOOD DR
Practice Address - Street 2:
Practice Address - City:SHIRLEY
Practice Address - State:NY
Practice Address - Zip Code:11967-3938
Practice Address - Country:US
Practice Address - Phone:631-543-6200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-17
Last Update Date:2010-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY12388101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02249145OtherCASAC