Provider Demographics
NPI:1144099987
Name:MANDEL, GRACE KELLY
Entity type:Individual
Prefix:
First Name:GRACE
Middle Name:KELLY
Last Name:MANDEL
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 1:393 DUNLAP ST N STE LL34
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55104-4202
Mailing Address - Country:US
Mailing Address - Phone:651-644-2440
Mailing Address - Fax:
Practice Address - Street 1:393 DUNLAP ST N STE LL34
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55104-4202
Practice Address - Country:US
Practice Address - Phone:651-644-2440
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-21
Last Update Date:2023-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician