Healthcare Provider Details

I. General information

NPI: 1558431528
Provider Name (Legal Business Name): MICHAEL MABANGLO LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/08/2006
Last Update Date: 07/08/2026
Certification Date: 07/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19270 HIGHWAY 12
SONOMA CA
95476-5414
US

IV. Provider business mailing address

19270 HIGHWAY 12
SONOMA CA
95476-5414
US

V. Phone/Fax

Practice location:
  • Phone: 707-939-6070
  • Fax: 707-939-6077
Mailing address:
  • Phone: 707-939-6070
  • Fax: 707-939-6077

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCS18876
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: