Provider Demographics
NPI:1225520125
Name:MANDER, CARALYN (LMSW)
Entity Type:Individual
Prefix:
First Name:CARALYN
Middle Name:
Last Name:MANDER
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:CARALYN
Other - Middle Name:
Other - Last Name:WALLIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMSW
Mailing Address - Street 1:103 WHITE SPRUCE BLVD
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14623-1610
Mailing Address - Country:US
Mailing Address - Phone:585-957-9234
Mailing Address - Fax:585-292-5847
Practice Address - Street 1:103 WHITE SPRUCE BLVD
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14623-1610
Practice Address - Country:US
Practice Address - Phone:585-957-9234
Practice Address - Fax:585-292-5847
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-06
Last Update Date:2018-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY100501104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty