Provider Demographics
NPI:1336624634
Name:MANDALA RESTORATIVE THERAPY
Entity Type:Organization
Organization Name:MANDALA RESTORATIVE THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/LICENSED CLINICIAN
Authorized Official - Prefix:
Authorized Official - First Name:TESSA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:MANDALA
Authorized Official - Suffix:
Authorized Official - Credentials:LCPC
Authorized Official - Phone:602-821-7850
Mailing Address - Street 1:5215 N RAVENSWOOD AVE STE 214
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60640-1670
Mailing Address - Country:US
Mailing Address - Phone:602-821-7850
Mailing Address - Fax:
Practice Address - Street 1:5215 N RAVENSWOOD AVE STE 214
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60640-1670
Practice Address - Country:US
Practice Address - Phone:602-821-7850
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-10-02
Last Update Date:2018-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)