Provider Demographics
NPI:1376276436
Name:MANDAL, KYLE JOMER CATAP
Entity Type:Individual
Prefix:
First Name:KYLE JOMER
Middle Name:CATAP
Last Name:MANDAL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 N JOHNSON AVE STE P
Mailing Address - Street 2:
Mailing Address - City:EL CAJON
Mailing Address - State:CA
Mailing Address - Zip Code:92020-2589
Mailing Address - Country:US
Mailing Address - Phone:619-441-1907
Mailing Address - Fax:619-441-1908
Practice Address - Street 1:700 N JOHNSON AVE STE P
Practice Address - Street 2:
Practice Address - City:EL CAJON
Practice Address - State:CA
Practice Address - Zip Code:92020-2589
Practice Address - Country:US
Practice Address - Phone:619-441-1907
Practice Address - Fax:619-441-1908
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-06
Last Update Date:2023-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
CA171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health