Healthcare Provider Details

I. General information

NPI: 1538218805
Provider Name (Legal Business Name): KELLY ANNE MANGIAFICO LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KELLY ANNE JOHNSON LCSW

II. Dates (important events)

Enumeration Date: 01/09/2007
Last Update Date: 07/24/2025
Certification Date: 07/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

175 PHILPOTT LN
BEAVER WV
25813-9501
US

IV. Provider business mailing address

175 PHILPOTT LN
BEAVER WV
25813-9501
US

V. Phone/Fax

Practice location:
  • Phone: 304-254-9262
  • Fax:
Mailing address:
  • Phone: 304-254-9262
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number8037
License Number StateCT
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberDP00947067
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: