Provider Demographics
NPI:1124138425
Name:MARDIS, NANCY (LCSW)
Entity type:Individual
Prefix:
First Name:NANCY
Middle Name:
Last Name:MARDIS
Suffix:
Gender:F
Credentials:LCSW
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 330
Mailing Address - Street 2:
Mailing Address - City:VICTOR
Mailing Address - State:CA
Mailing Address - Zip Code:95253-0330
Mailing Address - Country:US
Mailing Address - Phone:209-340-7900
Mailing Address - Fax:
Practice Address - Street 1:12755 N HIGHWAY 88
Practice Address - Street 2:
Practice Address - City:LODI
Practice Address - State:CA
Practice Address - Zip Code:95240-9323
Practice Address - Country:US
Practice Address - Phone:209-340-7900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2022-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCSW 186631041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA2376Medicaid