Provider Demographics
NPI:1184987745
Name:MANDELBAUM, PHYLLIS LOUISE (MSED)
Entity type:Individual
Prefix:MRS
First Name:PHYLLIS
Middle Name:LOUISE
Last Name:MANDELBAUM
Suffix:
Gender:F
Credentials:MSED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1364 HUDSON ROAD
Mailing Address - Street 2:
Mailing Address - City:TEANECK
Mailing Address - State:NJ - NEW JERSEY
Mailing Address - Zip Code:07666
Mailing Address - Country:UM
Mailing Address - Phone:201-357-2964
Mailing Address - Fax:
Practice Address - Street 1:22 MIDDLETON STREET
Practice Address - Street 2:WIECDC
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11211
Practice Address - Country:US
Practice Address - Phone:718-303-9400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-19
Last Update Date:2012-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist