Provider Demographics
NPI:1922707108
Name:DARAFEEV, MANDY
Entity Type:Individual
Prefix:
First Name:MANDY
Middle Name:
Last Name:DARAFEEV
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 1:350 E DEL MAR BLVD APT 223
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91101-2754
Mailing Address - Country:US
Mailing Address - Phone:626-922-7777
Mailing Address - Fax:
Practice Address - Street 1:111 S HUDSON AVE
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91101-2606
Practice Address - Country:US
Practice Address - Phone:626-683-8536
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-27
Last Update Date:2023-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA303745225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist