Provider Demographics
NPI:1891939443
Name:OLIPHANT, MANDI MICHELE (MA)
Entity Type:Individual
Prefix:MRS
First Name:MANDI
Middle Name:MICHELE
Last Name:OLIPHANT
Suffix:
Gender:F
Credentials:MA
Other - Prefix:MS
Other - First Name:MANDI
Other - Middle Name:MICHELE
Other - Last Name:BAUGHMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA
Mailing Address - Street 1:507 NATOMA STREET
Mailing Address - Street 2:
Mailing Address - City:FOLSOM
Mailing Address - State:CA
Mailing Address - Zip Code:95630
Mailing Address - Country:US
Mailing Address - Phone:916-934-2385
Mailing Address - Fax:916-338-6124
Practice Address - Street 1:507 NATOMA STREET
Practice Address - Street 2:
Practice Address - City:FOLSOM
Practice Address - State:CA
Practice Address - Zip Code:95630
Practice Address - Country:US
Practice Address - Phone:916-934-2385
Practice Address - Fax:916-338-6124
Is Sole Proprietor?:No
Enumeration Date:2009-04-27
Last Update Date:2015-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106H00000X
CA85949106H00000X
CALMFT85949106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA000008462OtherMEDI-CAL PROVIDER #