Provider Demographics
NPI:1376022590
Name:MANDALA, THOMAS (PT, DPT, SCS, CSCS)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:
Last Name:MANDALA
Suffix:
Gender:M
Credentials:PT, DPT, SCS, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:535 E 70TH ST.
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10021
Mailing Address - Country:US
Mailing Address - Phone:212-606-1005
Mailing Address - Fax:
Practice Address - Street 1:535 E 70TH ST.
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10021
Practice Address - Country:US
Practice Address - Phone:212-606-1005
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-08
Last Update Date:2021-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0442792251S0007X
DEJ1-0003957225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSports
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist