Provider Demographics
NPI:1861888778
Name:LOZANO, MANDIE MICHAEL (ATC)
Entity type:Individual
Prefix:
First Name:MANDIE
Middle Name:MICHAEL
Last Name:LOZANO
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:662 MCDONOUGH BLVD SE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30315-4439
Mailing Address - Country:US
Mailing Address - Phone:732-615-7564
Mailing Address - Fax:
Practice Address - Street 1:662 MCDONOUGH BLVD SE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30315-4439
Practice Address - Country:US
Practice Address - Phone:732-615-7564
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-08
Last Update Date:2015-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAT0022332255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer