Healthcare Provider Details

I. General information

NPI: 1609411842
Provider Name (Legal Business Name): MARISSA MANGUAL LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/12/2019
Last Update Date: 11/12/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1330 PARKWAY AVE STE 7
EWING NJ
08628-3006
US

IV. Provider business mailing address

365 SILVIA ST
EWING NJ
08628-3231
US

V. Phone/Fax

Practice location:
  • Phone: 609-403-6359
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number37PC00655100
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: