Provider Demographics
NPI:1497314504
Name:MANDERSON, CHARLOT MARIE
Entity Type:Individual
Prefix:
First Name:CHARLOT
Middle Name:MARIE
Last Name:MANDERSON
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 1:3507 STARCATCHER ST
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:FL
Mailing Address - Zip Code:34772-8272
Mailing Address - Country:US
Mailing Address - Phone:407-508-4444
Mailing Address - Fax:
Practice Address - Street 1:1002 S DILLARD ST
Practice Address - Street 2:
Practice Address - City:WINTER GARDEN
Practice Address - State:FL
Practice Address - Zip Code:34787-3991
Practice Address - Country:US
Practice Address - Phone:407-877-0029
Practice Address - Fax:407-358-5207
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-12
Last Update Date:2019-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency