Healthcare Provider Details

I. General information

NPI: 1376246223
Provider Name (Legal Business Name): MANGATA WELLNESS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/22/2023
Last Update Date: 03/22/2023
Certification Date: 03/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

613 SW CAMDEN AVE
STUART FL
34994-2924
US

IV. Provider business mailing address

613 SW CAMDEN AVE
STUART FL
34994-2924
US

V. Phone/Fax

Practice location:
  • Phone: 772-800-5591
  • Fax:
Mailing address:
  • Phone: 772-800-5591
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: KIMBERLEE FRISOSKY
Title or Position: OWNER
Credential: LCSW, CAP
Phone: 269-275-3508