Provider Demographics
NPI:1144042938
Name:MANDUJANO, MARIO MIGUEL
Entity type:Individual
Prefix:
First Name:MARIO
Middle Name:MIGUEL
Last Name:MANDUJANO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 MASSACHUSETTS AVE FL 3
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:02139-3345
Mailing Address - Country:US
Mailing Address - Phone:888-500-2067
Mailing Address - Fax:617-649-8520
Practice Address - Street 1:73 W MONROE ST STE 422
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60603-4955
Practice Address - Country:US
Practice Address - Phone:888-500-2067
Practice Address - Fax:617-649-8520
Is Sole Proprietor?:No
Enumeration Date:2024-10-31
Last Update Date:2024-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL150.1051401041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical