Provider Demographics
NPI:1568766673
Name:MANDARIC, EMILIE I (MS CCC SLP)
Entity Type:Individual
Prefix:
First Name:EMILIE
Middle Name:I
Last Name:MANDARIC
Suffix:
Gender:F
Credentials:MS CCC SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:170 COREY RD
Mailing Address - Street 2:
Mailing Address - City:BRIGHTON
Mailing Address - State:MA
Mailing Address - Zip Code:02135-8244
Mailing Address - Country:US
Mailing Address - Phone:617-383-6624
Mailing Address - Fax:
Practice Address - Street 1:170 COREY RD
Practice Address - Street 2:
Practice Address - City:BRIGHTON
Practice Address - State:MA
Practice Address - Zip Code:02135-8244
Practice Address - Country:US
Practice Address - Phone:617-383-6624
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-01-04
Last Update Date:2011-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MASP-7940-SL235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist