Provider Demographics
NPI:1447648472
Name:MANDRYK, THOMAS
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:
Last Name:MANDRYK
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 1:8437 CYPRESS TRL
Mailing Address - Street 2:
Mailing Address - City:WAYNESVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:45068-8398
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8437 CYPRESS TRL
Practice Address - Street 2:
Practice Address - City:WAYNESVILLE
Practice Address - State:OH
Practice Address - Zip Code:45068-8398
Practice Address - Country:US
Practice Address - Phone:937-885-4825
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-12-29
Last Update Date:2014-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOH1164587103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool