Healthcare Provider Details

I. General information

NPI: 1053201293
Provider Name (Legal Business Name): CHRISTINA MANGUERRA LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/08/2025
Last Update Date: 07/08/2025
Certification Date: 07/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

208 W COOLIDGE AVE
MODESTO CA
95350-4447
US

IV. Provider business mailing address

208 W COOLIDGE AVE
MODESTO CA
95350-4447
US

V. Phone/Fax

Practice location:
  • Phone: 209-722-4842
  • Fax:
Mailing address:
  • Phone: 209-722-4842
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number108598
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: