Provider Demographics
NPI:1922164383
Name:MANDALA PSYCHOLOGICAL SERVICES, P.C.
Entity Type:Organization
Organization Name:MANDALA PSYCHOLOGICAL SERVICES, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:YELENA
Authorized Official - Middle Name:
Authorized Official - Last Name:RAZDOLSKAYA
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:646-415-1915
Mailing Address - Street 1:2785 W 5TH ST APT 10E
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11224-4612
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2785 W 5TH ST APT 10E
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11224-4612
Practice Address - Country:US
Practice Address - Phone:646-415-1915
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY016210103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02821658Medicaid