Provider Demographics
NPI:1851155139
Name:MANDAKUNIS, PATRICIA ANN (LADC)
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:ANN
Last Name:MANDAKUNIS
Suffix:
Gender:F
Credentials:LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11063 55TH AVE
Mailing Address - Street 2:
Mailing Address - City:SEMINOLE
Mailing Address - State:FL
Mailing Address - Zip Code:33772-7231
Mailing Address - Country:US
Mailing Address - Phone:727-417-2126
Mailing Address - Fax:
Practice Address - Street 1:401 16TH ST SE STE 100
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:MN
Practice Address - Zip Code:55904-7974
Practice Address - Country:US
Practice Address - Phone:507-516-0030
Practice Address - Fax:507-516-0031
Is Sole Proprietor?:No
Enumeration Date:2024-02-07
Last Update Date:2024-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN306870101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)