Healthcare Provider Details

I. General information

NPI: 1376653774
Provider Name (Legal Business Name): JOSEPH D MANGINE PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 01/13/2021
Certification Date: 01/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

571 HIGH ST STE 12
WORTHINGTON OH
43085-4132
US

IV. Provider business mailing address

5040 FOREST DR SUITE 210
NEW ALBANY OH
43054-8167
US

V. Phone/Fax

Practice location:
  • Phone: 413-218-1105
  • Fax: 614-591-0710
Mailing address:
  • Phone: 413-218-1105
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License NumberP.7370
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number7370
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number7134
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: