Provider Demographics
NPI:1740695121
Name:MCISAAC, MANDI
Entity type:Individual
Prefix:MRS
First Name:MANDI
Middle Name:
Last Name:MCISAAC
Suffix:
Gender:F
Credentials:
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 788
Mailing Address - Street 2:
Mailing Address - City:LA CENTER
Mailing Address - State:WA
Mailing Address - Zip Code:98629-0788
Mailing Address - Country:US
Mailing Address - Phone:360-609-2990
Mailing Address - Fax:
Practice Address - Street 1:3204 NE 58TH ST
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98663-1430
Practice Address - Country:US
Practice Address - Phone:360-609-2990
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-24
Last Update Date:2014-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor