Healthcare Provider Details

I. General information

NPI: 1063384907
Provider Name (Legal Business Name): MICAELA MANGANELLO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2025
Last Update Date: 09/20/2025
Certification Date: 09/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 WESTERN AVE
SOUTH PORTLAND ME
04106-1704
US

IV. Provider business mailing address

50 ADAMS ST APT 1
BIDDEFORD ME
04005-2995
US

V. Phone/Fax

Practice location:
  • Phone: 207-292-1306
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2083A0300X
TaxonomyAddiction Medicine (Preventive Medicine) Physician
License NumberRN72898
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: