Provider Demographics
NPI:1659829760
Name:MANDALA HOUSE, LLC
Entity Type:Organization
Organization Name:MANDALA HOUSE, LLC
Other - Org Name:MANDALA HOUSE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JACQUELYN
Authorized Official - Middle Name:
Authorized Official - Last Name:GILLES
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:502-309-2403
Mailing Address - Street 1:1190 E BROADWAY
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40204-1712
Mailing Address - Country:US
Mailing Address - Phone:502-309-2408
Mailing Address - Fax:502-771-4283
Practice Address - Street 1:1190 E BROADWAY
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40204-1712
Practice Address - Country:US
Practice Address - Phone:502-627-0905
Practice Address - Fax:502-208-1058
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-18
Last Update Date:2019-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounselingGroup - Single Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty