Provider Demographics
NPI:1932709649
Name:MORDECAI, ANGELICA (LAC)
Entity Type:Individual
Prefix:
First Name:ANGELICA
Middle Name:
Last Name:MORDECAI
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 WILLIAM ST APT 3W
Mailing Address - Street 2:
Mailing Address - City:HASTINGS ON HUDSON
Mailing Address - State:NY
Mailing Address - Zip Code:10706-2833
Mailing Address - Country:US
Mailing Address - Phone:917-670-8564
Mailing Address - Fax:
Practice Address - Street 1:596 WARBURTON AVE
Practice Address - Street 2:
Practice Address - City:HASTINGS ON HUDSON
Practice Address - State:NY
Practice Address - Zip Code:10706-1504
Practice Address - Country:US
Practice Address - Phone:917-670-8564
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-30
Last Update Date:2021-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAP4118171100000X
NY006933171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist