Healthcare Provider Details

I. General information

NPI: 1780037747
Provider Name (Legal Business Name): JOHNMARK MANGIAMELI M.S.W
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/14/2016
Last Update Date: 04/29/2024
Certification Date: 04/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21 MCKINLEY RD
WORCESTER MA
01605-2131
US

IV. Provider business mailing address

21 MCKINLEY RD
WORCESTER MA
01605-2131
US

V. Phone/Fax

Practice location:
  • Phone: 845-282-9833
  • Fax:
Mailing address:
  • Phone: 845-282-9833
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number121185
License Number StateMA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: