Provider Demographics
NPI:1659938256
Name:MANDUJANO MOLINA, TRIDIANA
Entity Type:Individual
Prefix:
First Name:TRIDIANA
Middle Name:
Last Name:MANDUJANO MOLINA
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 1:9404 ROBERT BURNS CT
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28213-3562
Mailing Address - Country:US
Mailing Address - Phone:828-655-9403
Mailing Address - Fax:
Practice Address - Street 1:9404 ROBERT BURNS CT
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28213-3562
Practice Address - Country:US
Practice Address - Phone:828-655-9403
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-20
Last Update Date:2019-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician