Provider Demographics
NPI:1619013737
Name:MANDELBLATT, LISA CAROLYN
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:CAROLYN
Last Name:MANDELBLATT
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 1:7 HARTWELL ST
Mailing Address - Street 2:
Mailing Address - City:WALTHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02453-8907
Mailing Address - Country:US
Mailing Address - Phone:617-388-7439
Mailing Address - Fax:
Practice Address - Street 1:7 HARTWELL ST
Practice Address - Street 2:
Practice Address - City:WALTHAM
Practice Address - State:MA
Practice Address - Zip Code:02453-8907
Practice Address - Country:US
Practice Address - Phone:617-388-7439
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA5527225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics