Provider Demographics
NPI:1912364001
Name:DESROSIERS, MANDY
Entity Type:Individual
Prefix:
First Name:MANDY
Middle Name:
Last Name:DESROSIERS
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 1:1200 CALLOWHILL ST STE 101
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19123-3658
Mailing Address - Country:US
Mailing Address - Phone:215-825-8212
Mailing Address - Fax:215-825-8254
Practice Address - Street 1:1200 CALLOWHILL ST STE 101
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19123-3658
Practice Address - Country:US
Practice Address - Phone:215-825-8212
Practice Address - Fax:215-825-8254
Is Sole Proprietor?:No
Enumeration Date:2016-01-21
Last Update Date:2016-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator