Provider Demographics
NPI:1942208210
Name:KESTENBAUM, JOEL MANDEL (PHD)
Entity Type:Individual
Prefix:DR
First Name:JOEL
Middle Name:MANDEL
Last Name:KESTENBAUM
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 60347
Mailing Address - Street 2:
Mailing Address - City:ROSSFORD
Mailing Address - State:OH
Mailing Address - Zip Code:43460-0347
Mailing Address - Country:US
Mailing Address - Phone:419-661-2779
Mailing Address - Fax:419-661-0890
Practice Address - Street 1:922 DIXIE HWY
Practice Address - Street 2:
Practice Address - City:ROSSFORD
Practice Address - State:OH
Practice Address - Zip Code:43460-1333
Practice Address - Country:US
Practice Address - Phone:419-661-2779
Practice Address - Fax:419-661-0890
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-12
Last Update Date:2007-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2049103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
01388OtherPARAMOUNT HEALTH CARE
OH0348261Medicaid
OH0348261Medicaid