Provider Demographics
NPI:1902039316
Name:MANDAL, LUNA G
Entity Type:Individual
Prefix:
First Name:LUNA
Middle Name:G
Last Name:MANDAL
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 1:4845 ASHLEY PARK LN
Mailing Address - Street 2:#200
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28210-3334
Mailing Address - Country:US
Mailing Address - Phone:847-707-1034
Mailing Address - Fax:
Practice Address - Street 1:733 PLANTATION ESTATES DR
Practice Address - Street 2:
Practice Address - City:MATTHEWS
Practice Address - State:NC
Practice Address - Zip Code:28105-9116
Practice Address - Country:US
Practice Address - Phone:704-815-0371
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-01
Last Update Date:2012-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC10117235Z00000X
IL146.005645235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist