Provider Demographics
NPI:1538366547
Name:MANDELBAUM, EDWARD G (LCSW)
Entity type:Individual
Prefix:
First Name:EDWARD
Middle Name:G
Last Name:MANDELBAUM
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 PETER COOPER RD APT 7G
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10010-6630
Mailing Address - Country:US
Mailing Address - Phone:917-992-1621
Mailing Address - Fax:
Practice Address - Street 1:5 PETER COOPER RD APT 7G
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10010-6630
Practice Address - Country:US
Practice Address - Phone:917-992-1621
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-02
Last Update Date:2025-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY045481-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYN6R961Medicare ID - Type Unspecified