Provider Demographics
NPI:1790078756
Name:MANDELL, ERIC JAY (LCSW)
Entity Type:Individual
Prefix:MR
First Name:ERIC
Middle Name:JAY
Last Name:MANDELL
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2311 ALT 19
Mailing Address - Street 2:STE 1
Mailing Address - City:PALM HARBOR
Mailing Address - State:FL
Mailing Address - Zip Code:34683-2631
Mailing Address - Country:US
Mailing Address - Phone:727-331-3892
Mailing Address - Fax:
Practice Address - Street 1:700 VILLAGE WAY
Practice Address - Street 2:
Practice Address - City:PALM HARBOR
Practice Address - State:FL
Practice Address - Zip Code:34683-2935
Practice Address - Country:US
Practice Address - Phone:727-331-3892
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-05-24
Last Update Date:2011-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW103141041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical