MEDICARE: ANNETTE GINA MANGIAMELI PHD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	PSY17997	CA
2	103TC0700X	Clinical Psychologist	34289	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1063705101
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANNETTE GINA MANGIAMELI PHD

Provider Business Mailing Address
First Line	:	4349 JEKER DR
Second Line	:
City	:	PLANO
State	:	TX
Zip	:	75074-3571
Country	:	US
Telephone Number	:	619-762-8909
Fax Number	:

Provider Business Practice Location Address
First Line	:	4349 JEKER DR
Second Line	:
City	:	PLANO
State	:	TX
Zip	:	75074-3571
Country	:	US
Telephone Number	:	619-762-8909
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/23/2011
Last Update Date	:	05/10/2024

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