Provider Demographics
NPI:1790504686
Name:ALDAMA, MANDISA
Entity type:Individual
Prefix:
First Name:MANDISA
Middle Name:
Last Name:ALDAMA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MANDISA
Other - Middle Name:
Other - Last Name:GOGNA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2140 REDDING WAY
Mailing Address - Street 2:
Mailing Address - City:ATWATER
Mailing Address - State:CA
Mailing Address - Zip Code:95301-9627
Mailing Address - Country:US
Mailing Address - Phone:209-568-0978
Mailing Address - Fax:
Practice Address - Street 1:1101 M ST
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95354-0755
Practice Address - Country:US
Practice Address - Phone:209-522-9685
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-08
Last Update Date:2024-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist