Provider Demographics
NPI:1558660134
Name:MANDARINO, MARIA GRACE (LAC & LMT)
Entity Type:Individual
Prefix:MS
First Name:MARIA
Middle Name:GRACE
Last Name:MANDARINO
Suffix:
Gender:F
Credentials:LAC & LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13000 NO 103RD AVE.
Mailing Address - Street 2:SUITE 72
Mailing Address - City:SUN CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:85351
Mailing Address - Country:US
Mailing Address - Phone:623-262-7222
Mailing Address - Fax:
Practice Address - Street 1:13000 NO 103RD AVE.
Practice Address - Street 2:SUITE 72
Practice Address - City:SUN CITY
Practice Address - State:AZ
Practice Address - Zip Code:85351
Practice Address - Country:US
Practice Address - Phone:623-262-7222
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-21
Last Update Date:2018-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COACU 0001907171100000X
COMT0013491225700000X
AZMT-05542225700000X
AZLAC001032171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist