Provider Demographics
NPI:1417424748
Name:MANDE, DOROTHY FAIR (S/T MSPSE)
Entity Type:Individual
Prefix:MS
First Name:DOROTHY
Middle Name:FAIR
Last Name:MANDE
Suffix:
Gender:F
Credentials:S/T MSPSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:95 ATKINSON ST
Mailing Address - Street 2:
Mailing Address - City:CUTHBERT
Mailing Address - State:GA
Mailing Address - Zip Code:39840-5424
Mailing Address - Country:US
Mailing Address - Phone:229-310-0172
Mailing Address - Fax:
Practice Address - Street 1:95 ATKINSON ST
Practice Address - Street 2:
Practice Address - City:CUTHBERT
Practice Address - State:GA
Practice Address - Zip Code:39840-5424
Practice Address - Country:US
Practice Address - Phone:229-310-0172
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-24
Last Update Date:2018-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA$$$$$$$$$Medicaid