Provider Demographics
NPI:1811365018
Name:MANDARA, KELLY
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:MANDARA
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 1:500 FAIRWAY DR STE 102
Mailing Address - Street 2:
Mailing Address - City:DEERFIELD BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33441-1817
Mailing Address - Country:US
Mailing Address - Phone:888-880-9270
Mailing Address - Fax:
Practice Address - Street 1:4030 WAKE FOREST RD
Practice Address - Street 2:SUITE 349
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27609-6800
Practice Address - Country:US
Practice Address - Phone:336-465-8804
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-04
Last Update Date:2015-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist