Healthcare Provider Details

I. General information

NPI: 1104179753
Provider Name (Legal Business Name): MR. ANTHONY LUNDI MNGOLIA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/19/2012
Last Update Date: 10/19/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

81 PLANTATION ST
WORCESTER MA
01604-3069
US

IV. Provider business mailing address

484 MAIN ST
WORCESTER MA
01608-1893
US

V. Phone/Fax

Practice location:
  • Phone: 508-849-5600
  • Fax:
Mailing address:
  • Phone: 508-890-6519
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: