Healthcare Provider Details

I. General information

NPI: 1710938923
Provider Name (Legal Business Name): ANTHONY DAVID MANGIAFICO PHD, CNS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/12/2006
Last Update Date: 07/25/2021
Certification Date: 07/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2552 ALDRIDGE AVE
SOUTH CHESTERFIELD VA
23834-5306
US

IV. Provider business mailing address

2552 ALDRIDGE AVE
SOUTH CHESTERFIELD VA
23834-5306
US

V. Phone/Fax

Practice location:
  • Phone: 804-735-9595
  • Fax:
Mailing address:
  • Phone: 804-735-9595
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number0015000629
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: