Provider Demographics
NPI:1558718148
Name:MANDRELL, REBECCA
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:
Last Name:MANDRELL
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 1:9675 E D AVE
Mailing Address - Street 2:APT 1
Mailing Address - City:RICHLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49083-9348
Mailing Address - Country:US
Mailing Address - Phone:269-629-9214
Mailing Address - Fax:
Practice Address - Street 1:8530 M 89
Practice Address - Street 2:
Practice Address - City:RICHLAND
Practice Address - State:MI
Practice Address - Zip Code:49083-8205
Practice Address - Country:US
Practice Address - Phone:269-743-9984
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-24
Last Update Date:2016-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIM036077225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist