Provider Demographics
NPI:1710275466
Name:MANDEGARY, SAMIRA
Entity Type:Individual
Prefix:
First Name:SAMIRA
Middle Name:
Last Name:MANDEGARY
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 1:1615 E 17TH ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92705-8529
Mailing Address - Country:US
Mailing Address - Phone:714-640-9588
Mailing Address - Fax:
Practice Address - Street 1:1615 E 17TH ST
Practice Address - Street 2:SUITE 100
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92705-8529
Practice Address - Country:US
Practice Address - Phone:714-640-9588
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-15
Last Update Date:2013-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA07112011384331OtherMEDI-CAL