Healthcare Provider Details

I. General information

NPI: 1073166757
Provider Name (Legal Business Name): SAMANTHA J MANGINO LGSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/22/2019
Last Update Date: 03/18/2025
Certification Date: 03/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1609 6TH AVE E
BRADENTON FL
34208-1439
US

IV. Provider business mailing address

101 RIVERFRONT BLVD STE 710
BRADENTON FL
34205-8812
US

V. Phone/Fax

Practice location:
  • Phone: 413-481-1689
  • Fax:
Mailing address:
  • Phone: 941-776-4000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberSW17830
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberBP00945511
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: