Provider Demographics
NPI:1881296291
Name:DANIELS, MANDOLIN FAITH
Entity type:Individual
Prefix:
First Name:MANDOLIN
Middle Name:FAITH
Last Name:DANIELS
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 1:12337 VISTA RIDGE LOOP
Mailing Address - Street 2:
Mailing Address - City:EAGLE RIVER
Mailing Address - State:AK
Mailing Address - Zip Code:99577-7045
Mailing Address - Country:US
Mailing Address - Phone:801-897-0468
Mailing Address - Fax:
Practice Address - Street 1:16941 N EAGLE RIVER LOOP RD
Practice Address - Street 2:
Practice Address - City:EAGLE RIVER
Practice Address - State:AK
Practice Address - Zip Code:99577-7824
Practice Address - Country:US
Practice Address - Phone:907-726-5330
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-10
Last Update Date:2020-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK106S00000X106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician