Provider Demographics
NPI:1952839953
Name:MANDELKOW, ERICCA (PTA)
Entity Type:Individual
Prefix:
First Name:ERICCA
Middle Name:
Last Name:MANDELKOW
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6101 W RENO AVE STE 800
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73127-6592
Mailing Address - Country:US
Mailing Address - Phone:405-495-3085
Mailing Address - Fax:
Practice Address - Street 1:6101 W RENO AVE STE 800
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73127-6592
Practice Address - Country:US
Practice Address - Phone:405-495-3083
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-02
Last Update Date:2017-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1676225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant