Provider Demographics
NPI:1427619667
Name:MANDIGO, COLIN KENNETH (LMSW)
Entity type:Individual
Prefix:MR
First Name:COLIN
Middle Name:KENNETH
Last Name:MANDIGO
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2880 MISSION DR
Mailing Address - Street 2:
Mailing Address - City:SHELBYVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:49344-9580
Mailing Address - Country:US
Mailing Address - Phone:269-397-1760
Mailing Address - Fax:269-397-1761
Practice Address - Street 1:2880 MISSION DR
Practice Address - Street 2:
Practice Address - City:SHELBYVILLE
Practice Address - State:MI
Practice Address - Zip Code:49344-9580
Practice Address - Country:US
Practice Address - Phone:269-397-1760
Practice Address - Fax:269-397-1761
Is Sole Proprietor?:No
Enumeration Date:2019-06-27
Last Update Date:2025-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68011150661041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI6801115066OtherLARA BOARD OF SOCIAL WORK MASTERS SOCIAL WORKER LICENSE CLINICAL