Provider Demographics
NPI:1245799972
Name:MANDISEN, ROXANA
Entity Type:Individual
Prefix:
First Name:ROXANA
Middle Name:
Last Name:MANDISEN
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 1:232 E GISH RD
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95112-4706
Mailing Address - Country:US
Mailing Address - Phone:408-876-4284
Mailing Address - Fax:
Practice Address - Street 1:232 E GISH RD
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95112-4706
Practice Address - Country:US
Practice Address - Phone:408-876-4284
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-12
Last Update Date:2024-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA109241104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker