Provider Demographics
NPI:1750196069
Name:MANDIGO, VICTORIA M (LPTA, LMT)
Entity type:Individual
Prefix:
First Name:VICTORIA
Middle Name:M
Last Name:MANDIGO
Suffix:
Gender:F
Credentials:LPTA, LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7075 GRATIOT RD
Mailing Address - Street 2:
Mailing Address - City:SAGINAW
Mailing Address - State:MI
Mailing Address - Zip Code:48609-6904
Mailing Address - Country:US
Mailing Address - Phone:989-781-7700
Mailing Address - Fax:989-781-7733
Practice Address - Street 1:7075 GRATIOT RD
Practice Address - Street 2:
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48609-6904
Practice Address - Country:US
Practice Address - Phone:989-781-7700
Practice Address - Fax:989-781-7733
Is Sole Proprietor?:No
Enumeration Date:2025-02-12
Last Update Date:2025-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI23137040501225200000X
MI22271100922225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant