Provider Demographics
NPI:1568614790
Name:MITTLER, MANDY REBECCA (MA CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:MANDY
Middle Name:REBECCA
Last Name:MITTLER
Suffix:
Gender:F
Credentials:MA CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 SOUTHGATE RD
Mailing Address - Street 2:
Mailing Address - City:LOUDONVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:12211-1132
Mailing Address - Country:US
Mailing Address - Phone:518-785-6607
Mailing Address - Fax:
Practice Address - Street 1:30 SOUTHGATE RD
Practice Address - Street 2:
Practice Address - City:LOUDONVILLE
Practice Address - State:NY
Practice Address - Zip Code:12211-1132
Practice Address - Country:US
Practice Address - Phone:518-785-6607
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-10-21
Last Update Date:2012-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0117111235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist